^ 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


OPHTHALMOSCOPIC  DIAGNOSIS 


OPHTHALMOSCOPIC 
DIAGNOSIS 


BASED    ON 

TVPICAL   PICTURES    OF   THE    FUNDUS    OF   THE    EYE 

WITH    SPECIAL    REFERENCE   TO   THE   NEEDS   OF 

GENERAL   PRACTITIONERS   AND   STUDENTS 


BY 

Dr.  C.   ADAM 

ASSISTANT    AT    THE    KGL.    INIV. -AUGENKLINIK,   BEKLIN 

TRANSLATED   BY 

MATTHIAS   LANCKTON   FOSTER.   M.D. 

OPHTHALMIC    SURGEON    TO    THE    NEW    HOCHELLE    HOSPITAL:     MEMBER    OF    THE    AMERICAN 

OPHTHALMOLOGICAL    SOCIETY;     MEMBER    OF    THE    AMF.RICAN    ACADEMY    OF 

OPHTHALMOLOGY    AND     OTO-LARYNGOLOGY 


WITH  86   COLORED   PICTURES   ON  J>8   PLATES  AND   18  ILLUSTRATIONS 

IN   THE   TEXT 


^ 


THE   MEDICAL   ART   AGENCY 

Herai.I)   Sgi  arf.   BcM.niNG 

14i-14.,i   WEST  .'iihii   STREET 

NEW  YORK   (  1  TV 


REBMAN   COMPANY 

SOLE    AGENTS 


Copyright,  1913,  by 

REBMAN    COMPANY 

New  York 

All  Rights  reserved 


PRINTED  IN  AMERICA 


Co 

THE    MEMORY    OF 

MY    HOxNORED    TEACHER, 

JULIUS  V.  MICHEL 


HI 


Preface 

This  book  is  dedicated  to  tlie  nieniory  of  Jidlus  r.  Michel,  to  wlioin  is  due 
the  credit  of  its  conception,  its  purpose,  and  its  arrangement.  I  have  sinijjly 
followed  out  liis  idea  in  bringing  into  bold  relief  the  relations  that  exist 
between  diseases  of  the  eye  and  those  of  the  general  organism.  He  had 
the  satisfaction,  which  falls  to  the  lot  of  few,  to  see  the  ideas,  for  which  he 
had  fought  all  his  life,  receive  general  recognition  in  his  old  age.  His  views 
concerning  the  material  part  played  by  tuberculosis  in  the  etiology  of  diseases 
of  the  eye,  as  well  as  those  in  regard  to  the  diagnostic  importance  of  changes 
in  the  vessels  of  the  fundus,  are  now  generally  accepted  as  correct.  To  a 
much  less  degree  is  this  true  of  his  theory  concerning  myopia,  and  the  writer 
is  well  aware  that  he  may  excite  disj)ute  when  he  undertakes  to  present  this 
conception  in  the  present  book. 

In  the  title  the  word  "Atlas"  has  been  intentionally  avoided.  l)ecause  it 
emphasizes  the  illustrations;  the  words  "Ophthalmoscopic  Diagnosis"  have 
been  chosen  instead  in  order  to  indicate  that  the  real  purpose  of  the  book 
is  to  be  a  systematic  guide  to  diagnosis,  and  that  the  illustrations  are  intended 
to  serve  simply  as  aids  in  the  carrying  out  of  this  purpose.  The  manner 
in  which  the  text  has  been  written  and  arranged  has  also  been  made  sub- 
servient to  this  point  of  view.  A  glance  at  the  Table  of  Contents  will  show 
that  the  ophthalmoscopic  pictures  of  hemorrhages,  white  spots,  black  spots, 
etc.,  have  been  utilized  solely  as  a  means  of  classification,  and  that  the  attemjit 
has  been  made  to  bring  out  the  diagnosis,  and  to  impress  the  clinical  pictvire 
through  the  symptoms  there  depicted.  The  earlier  text-books  on  ophthal- 
moscopy, such  as  those  by  Jaeger,  Mauthner,  Schiceiggcr,  Dimmer,  Sehmidt- 
Jtimpler,  and  others,  started  from  the  clinical  concejitions  of  disease,  and 
porti'aved  these,  with  their  details  and  symptoms.  The  first  to  take  the 
ophthalmoscopic  symptom  as  a  basis  for  classification — at  least  in  literature, 
for  doubtless  many  besides  ourselves  had  ])reviously  used  it  in  teaching — was 
Ehchnig,  in  his  article  on  ophthalmoscopic  differential  diagnosis  in  Axenf eld's 
text-book.  I  have  followed  his  lead  in  many  places  where  his  method  of  presen- 
tation seemed  to  be  suitable  for  my  purpose. 

Special  attention  has  been  paid  to  those  diseases  of  the  eye  that  are 
related  to  general  diseases,  and  the  greatest  consideration  has  been  given 
to  the  varied  needs  of  the  general  practitioner,  the  neurologist,  the  gynecolo- 

vii 


vui 

gist,  and  tlu'  sypliilolo^ist,  in  tlio  ni.'inncr  in  wliicii  tiiey  arc  presented.  The 
reader  will  find  in  tlie  Index  not  only  the  individual  symptoms,  l)iit  also  con- 
nected with  them  tile  f^^neral  diseases  of  wiiieii   tliev  form  the  oeidar  sis^ns. 

Pathology  is  entered  into  only  so  far  as  seemed  advisahle  for  the  explana- 
tion of  the  ophthalmoscopic  pictures.  Brief  space  is  likewise  given  to  prog- 
nosis and  treatment.  Alost  of  the  pictures  were  taken  with  the  aid  of 
Thonicr's  demonstr.ition  oplitlialmoscope,  hut  they  ii.ivi'  been  reduced  about 
two  tliirds  in  size  for  i-cproduction  until  they  ])resent  the  inverted  image 
magnified  about  ten  times. 

I  cannot  conclude  without  expressing  my  obligations  to  those  who  have 
helped  me  in  this  work.  Above  all  I  wish  to  show  my  gratitude  to  Prof. 
Krueckmann,  who  undertook  the  great  labor  of  revising  the  manuscript,  and 
to  thank  my  colleagues  who  have  been  of  great  assistance  by  selecting  and 
furnishing  me  with  patients. 


Table  of  Contents 


PAGE 

The  Technique  of  the  Examination  with  the  Ophthalmoscope 3 

I.  Invirled  Imatje    3 

1.     Focussing  upon  the  Papilla  3 

•2.     The  Correct  Distance    -t 

3.  Correct   Accommodation   5 

4.  The  Question  of  Wearing  Glasses  6 

5.  Avoidance  of  Reflexes  from  the  Lens  and  Cornea 6 

6.  Indistinctness  of  the  Image   7 

7.  Incompleteness  of  the  Image 7 

8.  Investigation  of  the  Macula   7 

9.  Examination  of  the  Periphery S 

II.  Upright  Image 8 

Determination  of  the  Differences  of  Level   in    the    Fundus    (Paralactir  Displare- 

ment.  Perspective  Displacement.  Determination  of  the  Refraction) 9 

Place  and  Size  of  a  Lesion  in  the  Fundus   lU 

The  Dilatation  of  the  Pupil  for  the  Purpose  of  an  Ophthalmoscopic  Examination. .  10 

The  Normal  Papilla  and  the  Normal  Fundus i  j 

AxATOMiCAL  Review  1  j 

The  Ophthalmoscopic  Picture  of  the  Xormal  Papilla 17 

Form,  Color 1 " 

Margins  18 

Excavation  of  the  Papilla 18 

Vessels  23 

Arteries  and  Veins 22 

Venous  Pulse 2:i 

Vascular  Anomalies  -3 

The  Fundzis  OcuH 2i 

Types  of  the  Normal  Fundus 21 

Retinal  and  Chorioidal  Vessels 2.) 

Retinal   Reflexes   ; . . . .  ^G 

Macula   -(>' 

Conus  and  Staphyloma 33 

Differential   Diagnosis  of  the  White   Rings  and  Crescents  to  be   Found   in   the  Imme- 
diate Vicinitv  of  the  Optic  Xerve 33 

The  Conus 34 

The  Staphyloma   37 

The  Conus  Inferior 39 

Peripapillary  Atrophy  of  the  Chorioid    39 

The  Halo 40 

Medullated   Xerve   Fibers    40 

ix 


X 

PAOE 

Atrophy  of  the  Optic  Nerve 5i 

Differential   Dia);Iul^i^   of   the    Xarious    I'Drnis  of   .\tn)])liy 51 

Atrophic  Excavation 51 

Total  Atkophy   53 

1.  Simple  Atrophy 53 

2.  Nutritional  .Vtrophy   55 

,Vtro|)liy   Due  to  Oeeliision  of  the  .Vrteries 55 

3.  (jlaiieoniatons   .Xtrojjhy    55 

4.  Neuritic   Atrophy    57 

5.  Atrophy  of  the  Papilla  in   Retinitis  I'ijjnuntosa   58 

Pahti.m.,  Teimi'Ohai,,  ,\tiioi']iy  of  the  Optic   Nkiive    58 

Neuritis,  etc 7i 

I.  Keuness  of  the  Papilla  by  Itself   71 

II.  Optic   Neuritis ^- 

Differential  Diagnosis  between  Optic  Neuritis,  Choked  Disk  ami  Pseudoneuritis..  73 

Course  of  Optic  Neuritis 71 

What  Etiological  Conrliisions  can  be  Drairn  from  the  Ophthnlmoscojiic  Picture  of  an 

Optic  I\'euritis   75 

1.  Syphilitic  Optic  Neuritis   ( Neuro-retinitis  sjjecilica) 75 

2.  Tuberculous  Optic  Neuritis   76 

3.  Albuminuric  and   Diabetic  Optic   Neuritis    76 

i.     Arteriosclerotic  Optic  Neuritis   77 

5.  Otogenous  Optic  Neuritis  77 

6.  Optic    Neuritis    Caused    by    Abscesses    in    the    Orbit    and    Emiiyeinas    of    the 

Accessory  Sinuses  "i^ 

7.  Sympatlietic  Optic  Neuritis  78 

Other  Forms  of  Optic  Neuritis 78 

III.     AxiM.  Optic   NErniTis   (Neuritis   fascicuM    |)a|iilloiii.iciilaris;   toxic   neuritis;   retro- 

liulliar  neuritis)   '8 

Demonstration  of  a  Central  Scotoma  by  the  Aid  of  //./i/;'  Cliarts 79 

I^".     CiioKEU   Disk    '** 

Uliat  Etioloi/ical  Conchisioii.i  can     l>c    Urairn    from    the    Ophlhalmoscoiiic    Picture    of 

Choked  Disk 81 

Unilateral  Choked  Disk   81 

Bilateral   Choked    Disk    81 

Tumors 83 

Hemorrhages  on    the   Papilla    83 

Wounds  of  the  Optic  Nerve  83 

Vessels  of  the  Retina 97 

Preliminary    Remarks   on    the    Anatomy ^'^ 

Changes  in  the  Vessels  of  the   Retina ^8 

Elaboration  of  the  Above  Summary    ^8 

A.     The  Caliber   ^^ 

1.  Contraction   •  • ^8 

2.  Dilatation    '^^^ 

a.  Uniform  Dilatation  of  the  Veins  and   Arteries 100 

b.  Veinous   Hyperemia  with  the  .\rteries   Normal   or  Contracted 101 

3.  The  Differences  in  the  Proportional  Sizes  of  the   Arteries  and  of  the  Veins..  101 

4.  Unevenness  of  Caliber   


xi 

PAGE 

B.  The  Color  of  the  Vessels 102 

Color  of  the   Blood   Column 103 

Color  of  the   Vessel   Wall 10-2 

I 

Accompanying  Stripes lOi 

Transformation   into   White   Cords    103 

Deposits   in   or   over   the    Vessels    103 

C.  Changes  in   tlie    Nnnilicr  of  the  Vessels 104 

D.  The  Course  of  the  Individual  Vessel 105 

E.  The  Keflex   105 

F.  Phenomena   of    I'ulsation    lOG 

\'enoiis  and   Arterial   Pulse    106 

Retina ill 

A.  I'ltEI.I.MlNAUV     KkmAHKS    ON     THE     AnATOMY Ill 

The  Nutrition  of  the  Retina 113 

B.  General    Diagnosis    113 

Ophthalmosco])ic  Differentiation  of  Diseases   of  the   Inner  and  Outer  Layers  of  the 

Retina    and   of   the    Chorioid 113 

The  Position  of  the  Changes  in  the  Retina 113 

Retinitis    , Ill 

Are  Alterations  in  the  Pigment  Epithelium  Present  or  Not? Ill 

C.  Special    Diac.nosis     II j 

Retinal  Lesions  Which   Exliibit   Xo  Alterations  in  the  Pigment  Epithelium    (Dis- 
eases of  the  Inner  Layers) 11  j 

I,  Hemorrhages   110 

a.  Hemorrhages  as  the  Only,  or  the  Most  Important,  Change  in  the  Retina IK! 

Is  a  Differential  Diagnosis  Possible,  Based  on  These  Findings? 117 

Thrombosis  of  the  Main   Trunk   of  the   Central    Vein 117 

The  Causes  of  Retinal   Hemorrliage 118 

Differential   Diagnosis    119 

Recurrent   Hemorrhage  into  the  Vitreous 119 

b.  Hemorrhage   into   the    Retina    as   an   Accompanying   Syinptiau   of   Disease   of 
the   0])tic   Nerve    1-0 

II.  While  Spuls  in  the  Fundus 1;25 

Qucs/lon   I. 

Is   the   White   Spot   in    the   Retina,   or   in   the   Chorioid?    (Differential    Diagnosis   lietween 

Retinal    and    Chorioidal    Spots)     135 

1.  Trustworthy    Sym])toms    136 

2.  Adjuvant   Symptoms    126 

Cases  in  which  the  Diagnosis  is  Difficult 127 

Question  2. 

Is  this  a  Case  of  MeduUated  Nerve  Fibers  or  Not? 128 

Diagnosis  and  Importance  of  Medullated  Nerve  Fibers 128 

Question  3. 
Of  What  Nature  are  the  Spots  in  the  Retina? 128 

Question    ). 

In  How  Far  Can  the  Pathological  Construction  of  a  Spot  be  Determined  fnim  the  Ophthal- 
moscopic Picture? 129 


XII 

PAGE 

nitfiTcntial  Diafriiosis  of  White  Spots  from  a  PatliolDgical  Stanclpoint  (Connective  Tis- 
sue; CKdenia;  Varicose  'Ihickcning  of  the  Layer  of  Nerve  Kihers;  Fatty  Degen- 
eration ;    I'ilirinoii.s    Exudates) 129 

In  How  Far  Can  a  Conclusion  he  Drawn  from  the  Oplithalmoseopic  Picture  Concerning 
the  Etiology  of  White  Spots?  Differential  Diagnosis  of  White  Spots  from  the 
Etiological   Stand;-oi:;t    131 

a.  Bedridden,  Fehrile  Patients   ( Ketir.itis  Teptica) 13:2 

b.  Xoufehrile  Patients 133 

1.  lietinitis    aibuminuriea    133 

■J.  Ketinitis    ilialietica     134 

3.  Ketinitis  leucocytliainica  135 

4.  Ketinitis  ana?inica   135 

5.  Retinitis   syiihilitica    135 

6.  Retinitis  proliferans   133 

7.  In  Cases  of  Choked  Disk 136 

III,     Diffuse  Oiiacilii  of  the  Jirllim 149 

a.  Without  Great  Differences  of  Level 149 

1.  CEdema     149 

■2.  Diffuse  Infiltration  with  White  Blood   C)rpuscles 150 

3.  Necrosis  of  the   Inner   Layers   of  the   Retina 150 

4.  Vasomotor   Di.'turhance   with  Transudation 151 

5.  Flat    Detachment    of    the    Retina 151 

b.  Diffuse  Opacity  of  the  Retina  with  Marked  Differences  of  Level 152 

1.  Gibhous    Detachment   Caused    by    an    Exudate 152 

2.  Detachment  of  the  Retina  Caused  liv  a  Tumor  of  the  Chorioid 152 

3.  Glioma    cf    the    Retina 153 

Concerning  tlie  Prognosis  as  to  Life  of  Diseases  of  the  Retina  and  Cliorioid 153 

Chorioid 167 

Prcliminiirii    Remarks    cii    the    A ikiIo-kii 167 

General  Diagnosis  of  Diseases  of  the  Chorioid,  so  far  as  They  are  Caused  by  Diseases 

of  the   Vessels    168 

Etiology   cf   Chorioid;ti3    170 

Diagnosis 173 

.(.     Ccneral    Dinflnosis    17:2 

1.     The  Position  of  the  Lesions  in  the  Chorioid 173 

-'.     The   Sort  of   Pigmentation   and   Depigmentation 173 

3.     Are  Changes   Present  in   the   ^'essels  or   Not? 173 

1.     The  Form  of  the  Change 173 

5.     Differences    of    Level 173 

B.     SjirrinI  Dkninosis   174 

a.     Changes   in    the   Chorioid   and    Retina    Which    Occur   Chiefly  or    Exclusively   in 
•  the   Peri])hery    174 

CoUerlions  eif  Pitjment 174 

1 .  Bone    Corpuscles,    etc 1 74 

2.  Masses  of   Pigment,  \\'hich  are  often    Annular 175 

3.  Snuff  Fundus    175 

4.  Isolated  Spots  of   Pigment 175 


XIU 

PAGE 

Depigmentation  in  the  i'erijilieri/ 175 

1.  Discrete   Pigmentation    175 

2.  Superficial    Pigmentation    176 

b.  Changes  in  the  Chorioicl  in  the  Region  of  tlie  Macula 176 

1.  Arteriosclerotic   Changes   in    the   Macula 176 

2.  Changes   in   the   Macula  Caused   by   Contusions,  or   by   the   Presence  of   a 

Foreign   Body   in   the   Eye 177 

3.  Changes  in  the   Macula  Caused   by   High  Myo])ia 177 

4.  So-called  Coloboiua  of  the  Macula 177 

c.  The  Changes  in   tlie  Chorioid   about  the   Optic    Nerve 177 

Peri]>apillary  Sclerosis  of  the   N'esseN 178 

Hujitures  of  the  Chorioid 178 

Coloboma  of  the  Chorioid 178 

d.  The   Disseminated   Form  of   Chorioretinitis 179 

Fresh  Spots   1 79 

Old    Atrophic    Sjiots     179 

1.  Atrophic  Spots  Without  Visible  Changes  in  the  Vessels 180 

2.  Atrophic  Spots  with  Changes  in  the  \'essels 180 

Changes  in  the  Chorioid  with  Differences  of  Level 181 


List  of  Figures  in  the  Text 

FIG.  PAGE 

A. — The    Correct    Distance    5 

f5. — Correct    Accommodation    6 

C. — Examination   of   the   l^ft    Eye 8 

D. — Microscopic  Section  Through  a  Normal  Optic  Nerve IG 

E. — Small  Excavation  in  the  Temporal  Part  of  the  Papilla 19 

F. — Schematic  Drawing  of  the  Fundus,  Upright  Image 20 

G. — Variety  in  the  Courses  of  the  Retinal  Vessels 21 

H. — Distribution  of  Pigment   21 

I. — Head  of  the  Optic  Nerve  in  Myopia,  after  Ftichs 35 

J. — Schematic  Sketch  to  Show  how  the  Papilla  is  Caused  to  Appear  out  of  Drawing  in 

High  Myopia   38 

K. — In   this   Case   the    Ectasia   does    not    I.ie    Exactly   at    the    Posterior    Pole,   but    rather 

Below  it 38 

L. — In  this  Case  the  Ectasia  Lies  to  the  Nasal  Side  of  the  Posterior  Pole,  so  that  the  Pa- 
pilla Occupies  the  Bottom  of  its  Cavity 38 

M. — Glaucomatous    Excavation    56 

N. — Deep  Physiological   Excavation    56 

O. — Neuritis    Optica    77 

P.— Choked   Disk    82 

Q. — Anatomy    of   the    Retina,   after   Greeff 112 

R. — Total,  Funnel-shaped  Detachment  of  the   Retina 153 


XV 


List  of  Plates 


PLATE  FIG.  PAGE 

I.  1.     Normal   Fundus  of  the  Unifonn,   Sti|ipli-il   Typo -8 

I.  -2.  N'ormal    Fuuthis   of   the    Tessehitecl    Type,   with    Xiimerous    Reflexes    from 

the  Retina   -« 

11.  3.     Alliinotie  Fundus  30 

III.  I.     Coiius    I'emporalis    *^ 

III.  5.     Conus   Temporalis;    Supertraetion    in    "Sehool"    Myopia H 

IV.  (i.     Commencing  Staphyloma  Postieum  in  "Congenital"  Myopia 46 

IV.  7.     Crescentic    Sclerosis   of   the   Chorioid    Due    to    Arteriosclerosis 46 

V.  8.     Conus    Inferior;    Partial   Alhiuism 48 

V.  9.     MeduUated   Nerve   Fihers    48 

VI.  10.     Simple  White  Atrojihy  of  the  Optic  Nerve Bi 

VI.  11.     Simiile  Gray  Atrojihy  of  the  ()])tic  Nerve t'i 

Vll.  l-\     Atrophy   after   Intlannnation   of  tlie   Ojitic   Nerve,   Neuritie   Atrophy ()4 

VII.  i:i.     Atrojihy   of   the   Optic    Nerve   after   Clioked    Disk (U 

VIII.  14.     tllaucomatous    Excavation    and    Atrojiliy : 66 

VIII.  15.     Large   Physiological   Excavation    <i6 

IX.  16.     Atrophy  of  the  Optic  Nerve  after  Occlusion  of  the  Central  Artery 68 

IX.  17.     Partial,  or  Temporal,  Paleness  of  the  0|)tic  Nerve (.'8 

X.  18.     Optic  Neuritis   86 

X.  19.     Tuhercle  at   the   I'^ntrance  of  the   Optic   Nerve 86 

XI.  50.     All>uminuric   Optic    Neuritis    ( All)uminuric   Choked    Disk) 88 

XI.  -21.     Optic  Neuritis  Undergoing  Involution    88 

XII.  22.  The  Optic   Nerve  in   a  Case  of  Sinus  Tliromljosis   Couijilicating   an  Otitis 

Media    ^0 

XIII.  23.     Conuuencing  Choked  Disk   9- 

XIII.  2i.     Conunencing  Choked  Disk   9- 

XIV.  25.     Old  Choked  Disk  with  a  Very   Ahundant   Develo])inent  of   Vessels 94 

XIV.  26.     Choked    Disk   at   its    Acme 94 

XV.  27.  Occlusion  of  the  Central  Vein  of  tlie  Retina  (Aiiojilexia  Saiiguinea  Retina')  1J2 

XV.  28.     Occlusion,  or  Thromhosis,  of  a  Single  Vein  of  the  Retina 122 

XVI.  29.     Foreign    Body    in    the    Retina    and    Chorioid 1-H 

XVII.  30.     Retinitis    Albuminuriea     138 

XVII.  31.     Retinitis    Albuminuriea    1-58 

XVIII.  32.     Neuroretinitis    Albuminuriea     '40 

XVIII.  33.  Neuroretinitis  AUmminurica  Ciravidaruin  wilh   net.u-luuent  of  the  lietina..  140 

XIX.  34.     Very    Severe    Neuroretinitis    Alliuminurica 142 

XIX.  35.     Neuroretinitis    Diabetica    142 

XX.  .36.     Retinitis   Proliferans   in   Diabetes    144 

XX.  37.     Retinitis    Proliferans   in   Syjihilis    144 

XXI.  38.     Retinitis    Luetica    1  i'' 

XXI.  39.     The  Same  Case  Six  Weeks  Later 1 16 

XXII.  40.     Sympathetic  Optic   Neuritis   and   Cliorioiditis 148 

XXTI.  41.     Colloid   Deposits  on   the   Vitreous    Lamella   of   the   Chorioid 148 

XXIII.  42.     Retinitis    Luetica    l-5'> 

XXIII.  43.     Commotio    Retina-,    or    Berlin'^    0])acity 156 

XXIV.  44.  Sudden  Total  Occlusion  of  the  Central   Artery,  the   sivcalled    Embolism..  158 
XXIV.  45.     Occlusion   of  the  Central   .Artery  in  a   Later  Stage 158 

XXV.  46.     Flat  Detachment  of  the  Retina 1«0 

xvii 


xviii 


PLATE 

FIG. 

\.\V. 

17. 

XXVI. 

■IS. 

XXVI. 

lil. 

XXVll. 

51). 

XXVlll. 

:a. 

XXVIII. 

5-'. 

XX I  \. 

.5:5. 

XXX. 

3i. 

XXXI. 

oo. 

XXXI. 

jli. 

XXXII. 

57. 

XXXIII. 

5S. 

XXXIW 

59. 

xxxi\-. 

(iO. 

XXXI  \. 

(U. 

XXXIV. 

G2. 

XXXV. 

63. 

XXXV. 

61. 

XXXVI. 

65. 

XXXVI. 

66. 

XXXVII. 

67. 

XXXVII. 

68. 

XXXVIII. 

(;<). 

XXXIX. 

70. 

XXXIX. 

71. 

XL. 

7-'. 

XL. 

73. 

XLL 

74. 

XI.I. 

75. 

XLII. 

76. 

XLIL  77. 

XLIIL  78. 

XLIV.  79. 

XLV.  80. 

XLV.  8L 

XLVI.  8-2. 

XLV  I.  83. 

XLVIL  84. 

XLVIL  85. 

XLVI  1 1.  86. 


I'AGE 

Partial   Flat   Dctaohmcnt   of   the    lictiiia 160 

Large    CJilibous    nctailiiiiciit    of   tin-    Uctiiia liiJ 

Detachment  of  the  Hetina  Caused  by  a  Tumor  of  the  C'liorioid 1(U 

Small   Glioma   of   the   Uetiiia Kit 

Hetinitis  I'ipmentosa,  or  I'ifimeiil  Degein-ralioii  of  the  lietiiia 181. 

Secondary    Hetiuitis   I'lgnieiitosa ISt 

Grossly    I'ifrnuTitcil    I'liiulus   of    Hereditary    .Sy|hilis l^a 

Schematic   Pictures  of  Diseases  of  the  Chorioidal   Vessels 188 

The  so-called   Pepper  and   Salt    I'uiidus   of    Ilere<litary   Syphilis 1;)0 

^'cry   Severe  Chorioretinitis   Due   to    Hereditary   .Syjihilis,   with   .\tniphy 

of  the  Oi)tic  Nerve   1!)0 

Chorioretinitis  Due  to  Hereditary  Syphilis l'J2 

Chorioretii'.itis  Due   to  Hereditary   Syi.hilis,   with   Atrojihy   of   the   Optic 

Nerve    191. 

Early   Stage   of   .Vrteriosclcrosis   of   the   Ves.sels   of   the   Chorioid    in    the 

Hegion   of  the  Macula    196 

■Senile  Degeneration  of  the  .Macula 196 

Senile  Degeneration  of  the  .Ma<'ula 196 

Senile  Degeneration  of  the  Macula 196 

Finely    Pigmented    Fundus   of   Hereditary    Syphilis,   the   so-called    Snutf 

Fundus     198 

Sclerosis  of  the  Vessels  of  the  Chorioid  in  the  Region  of  the  .Macula....    198 

Peripapillary  Sclerosis  of  the  A'essels  of  the  Chorioid 200 

Peripheral  Patch  of  Sclerosis  of  tlie  X'esscls  of  the  Chorioid 200 

Great   Sclerosis   of  the   X'essels   of  the   Chorioid,   and   Less  of   Those   of 

the    Hetina    202 

E.xtrcmi;  Sclerosis  of  the  Vessels  of  the  Chorioid 20-2 

Chorioretinitis    Albuminurica    20i 

High  Myopia;  Temporal  Staphyloma;  Change  in  the  .Macula 206 

High  Myopia;  Circular  Staiihvloma;  Sclerosed  N"essels  of  the  Chorioid..  208 
High   Myopia   with   Circular   .Sta]ihylonia   and   a   \'ery   Great   Change   in 

the  .Macula   208 

High   Myopia  with   a    so-called   Sta|)hyloma   Veruni 208 

Atrophic  Spots  in  the  Chorioid  with  Plainly  .Sclerosed  Vessels 210 

Neuritic  Atrophy  ot  the  Optic  Nerve;  .\trophic  .S|K>t  in  the  Periphery..  210 
Extensive  so-called  Chorioretinitis  Disseminata  with  Scleroses  of  the  \'es- 

scls  of  the  Chorioid  212 

So-called    Chorioretinitis    Disseminata   with    Scleroses   of   the    Vessels   of 

the  Chorioid  212 

Chorioretinitis   Tuberculosa    211 

Chorioretinitis    Tiiberculosa    216 

Healed   Inflammatory   (Tuberculous)    Spot  in   the   Macula 218 

Fundus  of  the  Eye  in  .-\cute  Miliary  Tulierculosis 218 

Extensive  Rupture  of  the  Chorioid  with  I)evel()]]mcnt  of  Cormective  Tis- 
sue in  Places    --0 

Rupture  of  the  Chorioid 220 

Coloboma    of    the   Chorioid 222 

Extensive   Coloboma   of  the  Chorioid 222 

Normal   Fundus  of  a   Rabbit 22i 


Alphabetical  Index  of  Figures  on  the  Plates 

The  Numerals  indicate  the  Numbers  of  the  Colored  Figures 


Alliinisni.  partial,  8 
Alluiiniiuiria,   liil,  77 
neuritis,  ai'c   Neuritis 
neuroretiiiitis.  32,  33,  34 
occlusion  of  tlic  central  vein,  '27 
retinitis,   30,  31 
Alliuniinuric  choked  disk,  30 
AjiO]ilexia  -.anguinea  retina,  27 
Arteriosclerosis,   7,  59-C'-',  64,  65,  67 
macula,   59-62,   64 
neuritis,  xee    Neuritis 
occlusion  of  tlie  central  vein,  27 
Atrophy  of  the  optic  nerve,  after  choked  disk, 
13" 
after  occlusion  of  the  central  artery,  16 
glaucomatous,  14 
gray,   11 

in   retinitis  pigmentosa,  51 
multiple   sclerosis,   17 
nenritic,  12 
retinitic,  51 
simple,  10,  11 
syphilis,  acquired,  75 
syphilis,  inherited,  56,  58 
tahetic,  11 

temporal  paleness,  17 
white,  10 
yellow,  51 

Birling  o]iacity,   43 

Central   artery,   occlusion  of,   16,  39 

sudden,   44,   45 
Cherry   red   spot,  44,  45 
Choked  disk,  albuminuric,  20 

abundant  development  of  vessels,  25 
i.t  its  acme,  26 
atrophy,  see  Atrophy 
ditl'iise,    26 

hemorriiages  of  retina,  26 
iiKi)>ient,  23,  24 
knob-shaped,  2j 
Chorioid.  changes  of,  51-85 
albuminuria,  69,  77 
arteriosclerosis,   59-62,   64,   65,   67 
colobonia,  84,  85 
diffuse,  67,  68,  76,  77 
heredosyphilis,  68 
macula,  64 
myopia,  6,  70-73 
peripapillary,  65 
]ieripheral,  60,   75 
rupture,   82,  83 
schematic  pictures,  54 
syphilis,  66,  74,  75,  76 
tuberculosis,  78-84 
vessels,  64-77 
Chorioretinitis,  76-80 
albuminuric,  69,  77 


Chorioretinitis,    arteriosclerotic,    59-62,    64,    65. 
67 

heredosyphilitic,  53,  55-58,  63,  68 

myopic,  70,  73 

jiigmented,   51 

proiiferans.  82 

sympathetic,  40 

syphilitic,  60,  74,  75,  76 

tuberculous,   78-84 
Cilioretinal  artery,  4 
Coloboma  of  the  chorioid,  84,  85 
Commotio  retinae,  43 
Connective   tissue,   chorioid,  82 

retina,  36,  37 
Connective  tissue  rings,  1,  2 
Conus  inferior,  8 

temporalis,  4,  5 

Depigmentation,  55,  57,  58,  63 
Detachment  of  the  retina,  arteriosclerotic,  47 
caused  by  a  tumor  of  the  chorioid,  49 
flat,  46 
glioma,  50 

in  nephritis  gravidarum,  33 
large  gibbous,  48 
partial  flat,  47 
Develo]inient  of  coiuiective  tissue,  82 
Diabetes,  colloitl  deposits  on  the  vitreous  lamel- 
la, 41 
liemorrhage.   35 
neuroretinitis,  35 
varicosities.  36 
white  spots,  35,  36 

Excavation,   glaucomatous,   14 
physiologic,  15 

Foreign  bodies  in  the  retina,  29 
Fundus,  albinotic,  3 

in  myojiia,  70-73 

normal,   1,  2,  3 

sti])pled,  1 

tesselated,  3 

Glaucoma,  14 
Cilaucomatous  atrophy,  14 

excavation,  14 

halo,  14 
Glioma  of  retina,  50 

Halo,  14 

Intravascular  spaces,  2 

Lamina  cribrosa,  meshes,  5, 

Macula,  changes  in,  myopic, 
reflexes,  2 
senile,   59-63 
stT,  30,   34 


15 

70-73 


XX 


McthiUated  nerve  fibers,  !) 

in  the  rahhit,  H(i 
M(■IliIl}riti^.  sy])liilitic,  atrojihy,  58 

tiilnTC-iiloiis,    neuritis,   81 
Miliary   tuherculosis,  81 
iliiltiiile  si-lerosis,  see  Atrophy 
Jlyopiiu,  aequirecl   (school),  i,  5 

conjrenital,  H 

diseases  of  the  vessels  i)f  the  chorioid,  70-73 

selereetasia,  7;5,  85 

sta|)hyloma   iiostiemn,  (>,  70-73 
venim,  73 

Weiss-Olto  shadow-ring,  73 

Naeviis  of  retina,  31 
Nephritis,  sec   .\lbnniin\iria 
Neuritis,  see  tilso  Neuroretiiiitis 

alhuminurie,   -'0 

arteriosclerotic,   2\ 

defreneralion   of   retina,  JO 

lieniorrhages  of  retina,  -0 

in  otitis   media,  JJ 

interstitial,    18 

migration   of   pigment,   -21 

miliary   tnhercniosis,  84- 

jieripajiillary   oedema,   18,  2-2 

svpliilitic.    18 

tuhereulous,  19,  81 

undergoing  involution,  21,  37 
Neuritic    atro|iliy,    IJ 
Xeuroretiniti^,   alliuminurica,  3:?,  33,  3i,  39 

liiabetic,  Sj,  3(j 

sjinpathetic,  -10 

Occlusion   of   the  central   artery,   45 
Otitis   neuritis,  22 

Papilla,  normal,   1,  2.  3,   15 

transversely  oval,  8 
Peri]iapillary  (inlema,  see  Neuritis 
Pigment,  degeneration,  51,  52 

migration,  75 

rings,  1 

Rabbit,  mcdullated  nerve  fibers,  22i 
Retina,  allniininuria,  20.  31,  32.  33,  34,  69 
aneiiri^^m,  3(i 

atrophy  of  optic  nerve,  see  Atrophy 
changes  in  arteriosclerosis,  21,  27,  28,  44,  45, 
()7 

diabetes,  34,  36 

heredosvphilis,  56-58 

s\7>hilis',  12,  18.  27,  28,  37,  38,  39,  42,  44,  45 
congestion   through  nedema,  22.  78 

through  niedullated  nerve  fibers,  9 
connective  tissue,  3(i,  37 
degeneration  in  neuritis,  see  Neuritis 
detachment,  49 

disajipearance  of  vessels,  36,  56 
dis|)ro])ortion  of  vessels,  24,  26,  28,  32 
extravasation  of  vessels,  33 
exudates,  38,  39 
fatty  degeneration,  SO 


Retina,   foreign  bodies,  29 

glioma,   50 

hemorrhage,  27,  2ii,  31 
in   diabetes,  35,  36 
striated,  32 

injuries,  29,  43,  82,  83 

migration  of  pigment,  12,  16,  21  , 

navus,  .31 

normal,  1-9 

occlusion,   16 

(Tdema,  9,  31,  42,  44 

reflexes,   2,  30 

retinitis  pigmentosa,  51 

vessels,  i6-58 

white  spots  in  albuminuria,  30 
in  diabetes,  35,  36 
Retinitis,  see  also  Neuroretinitls 

albuminurica,  30,  31 

pigmented,  51 

jiroliferans,  36,  37 

se<'oiuiary  iiigmented,  52 

syphilitic.    I-' 

Schematic  ]iictures  of  the  diseases  of  the  chori- 

oidal    vessels,   54 
Scleral  ring.  1,  2 
Scleral  vessels,  84,  85 
Sclerectasia,  73,  85 
Sclerosis,  see  Retina  uiiil  Chorioid 
Senile  changes  in  macula,  59-62 
Snuff    fundus,   63 
Stajihylonia   jjosticum,  6,  70-73 

verum,   73 
Stipjiled   fundus,   1 
Supertraction   crescent,   5 
S3^llpathetic   inflammation,  neuritis,  40 

white  spots,   40 
Syphilis,  atrophy  of  the  optic  nerve,  12,  75 
"cordlike  bundles  of  connective  tissue,  37 
diseases  of  the  vessels  of  the  chorioid,  66,  74, 

75,  76 
diseases  of  the  vessels  of  the  retina,  38 
inherited,  atrophy  of  the  optic  nerve,  56-58 
depigmentation,  55,  56,  57,  58 
diseases  of  the  vessels  of  the  chorioid,  58,  68 
diseases  of  the  vessels  of  the  retina,  56-58 
finely  pigmented  fundus.  63 
grossly  jiigmented  fundus.  53 
l)e))per  and  salt   fundus.  55 
snuff  fundus.  63 
occlusion  of  the  retinal  artery,  38,  39 
retinitis.  42 

Tem])oral  paleness.  17 
'iesselated   fundus,  2 
Thrombosis  of  the  central  vein,  28 
'1  uberculosis,  chorioretinitis,  78-84 

Vena  centralis,  27,  28 
Vortex  veins,  3 

Weiss-Otlo  shadow-ring,  73 


Preliminary  Remarks  on  Technique 


The  Technique  of  the  Examination  with  the  Ophthalmoscope 

cannot  be  taught  in  full  detail  in  such  a  book  as  this,  but  a  few  suggestions 
may  be  of  aid  to  those  who  are  inexperienced. 

I.    INVERTED    IMAGE 

1.  Focussing  upon  the  Papilla. 

The  light  should  be  placed  behind  and  to  the  side  of  the  patient,  so  that 
it  will  not  shine  into  his  eye. 

The  complaint  is  heard  very  often  in  every  class  in  ophthalmoscopy  that 
the  student  can  focus  quite  well  upon  the  papilla  of  the  left  eye  of  the  patient, 
but  not  upon  that  of  the  right.  The  reason  for  this  is  that  the  patient  obeys 
too  literally  the  customary  direction,  that  he  should  look  at  the  corresponding 
ear  of  the  observer. 

The  object  of  this  direction  is  to  cause  the  patient  to  look  past  the  eye 
of  the  observer,  or  the  mirror,  at  a  certain  distance,  i.e.,  15  cm,  with  his  own 
eye  slightly  inclined  toward  his  nose,  in  order  that  the  papilla,  which  lies 
to  the  nasal  side  of  the  macula,  may  confront  the  observer.  But  when  the 
physician  holds  the  mirror  before  his  right  eye,  the  distance  between  it  and 
his  right  ear  is  considerably  less  than  the  requisite  1.5  cm:  it  is  a  hand- 
breadth,  some  10  cm  too  short,  while  the  distaiice  from  the  left  ear  to  the 
mirror  is  about  right.  It  is  therefore  necessary  that  on  the  side  on  which 
the  phA'sician  holds  the  mirror  the  patient  should  look  not  at  the  car  of 
the  observer,  but  ])ast  it  at  the  distance  of  about  a  handbreadth.  in  order  to 
bring  his  papilla  into  view. 

Furthermore,  it  is  not  advisable  to  have  the  patient  look  at  the  ear  of 
the  observer,  because  he  then  accommodates,  and  a  contraction  of  the  pupil 
accompanies  acconnnodation :  therefore  it  is  better,  even  when  the  patient  is 
sitting  on  the  opposite  side,  to  direct  him  to  look  not  at  the  c;ir,  but  past 
it,  as  though  at  an  object  in  the  distance.  The  direction  usually  given  should 
therefore  be  made  more  precise,  so  as  to  read: 

In  order  to  present  his  papilla  the  patient  is  to  look  at  a  distance  past  tin- 
ear  of  the  observer  corresponding  to  the  eye  that  is  being  examined;  if  the 
latter  is  on  the  side  on  ichirh  the  phi/sician  holds  the  mirror,  he  shoidd  look 
about  a  handbreadth  aicaii  from  the  ear,  if  it  is  on  the  other  side,  the  line  of 
i-ision  should  pass  close  to  the  ear. 

3 


The  correct  presentation  of  tlie  pajiilla  is  a  matter  of  tlie  f^reatest  iinpor- 
tjince,  althougli  it  is  generally  uiulervahied  by  beginners.  It  is  perhaps  the 
most  importiint  point  connected  with  the  examination,  for  it  may  be  said 
without  exaggeration  that  in  about  three  quarters  of  all  the  cases  a  failure 
on  the  part  of  anyone  using  the  opiithalmoscope  is  to  be  ascribed  to  an 
incorrect,  or  inexact  presentation  of  the  papilla,  or  to  an  incorrect,  or  inexact 
direction  to  the  patient  where  to  look.  Let  it  once  be  realized  that  the  retina 
comprises  an  area  of  several  square  centimeters,  that  within  that  surface 
the  papilla  is  only  a  minute  point,  not  much  larger  than  the  head  of  a  pin, 
and  it  will  i)e  appreciated  that  a  considerable  degree  of  accuracy  is  necessary 
to  properly  present  this  point  in  tlie  relatively  large  surface. 

Hincc  it  should  be  tlic  rule  in  nil  cases  in  zs.'hich  the  attempt  to  see  the 
papilla  is  not  irnmediatel//  successful,  to  interrupt  the  examination  and  to 
ascertain  first  of  tdl  -iciutlicr  the  position  of  the  patient's  ctjc  is  correct. 

After  the  patient  has  been  told  in  what  direction  to  look  the  observer 
at  first  closes  the  eye  which  is  not  :it  the  ophthalmoscope  and  throws  light 
into  the  eye  of  the  patient  without  the  iiiter]>osition  of  a  lens.  By  doing 
this  he  learns  two  things:  1,  whether  the  refractive  media  are  clear,  or  opacities 
are  [)rescnt  in  the  cornea,  lens,  or  vitreous,  which  may  interfere  with  the 
examination ;  and,  l!,  whether  the  papilla  is  actuall}'  before  him.  If  the 
patient  presents  his  papilla  cori'ectly  the  pupil  does  not  appear  to  be  as 
red  as  it  otherwise  does,  but  is  of  a  whitish  yellow,  Ixcause  the  tone  of  its 
color  is  determined  by  that  of  tlie  papilla. 

When  this  has  been  ascertained  to  be  the  case  a  lens  is  placed  before  the 
eye  and  the  observer  tries  to  obtain  a  sharply-  defined  image  of  the  papilla. 
To  attain  this  end 

2.  The  Correct  Distance 

between    the   optical   systems,    eye — lens — ej-e,    is    of    paramount    importance. 
When  a  +13  D  lens  ^  is  used  the  distances  are  as  follows: 

The  total  distance  between  the  physician  and  the  patient  is  approximately 
40  to  \h  cm  (see  Fig.  A  in  the  text),  of  which  7  cm  are  between  the  patient 
and  the  lens,  32  to  37  cm  between  the  lens  and  the  physician.  This  is  pro- 
vided that  both  the  physician  and  the  patient  are  emmetropic.     If  either  one 

f 
^  The  strenprth  of  a  convex  lens  may  be  ascertained  in  a  very  simple  manner  b.v 
producing  the  picture  of  any  source  of  light  upon  a  piece  of  paper  by  means  of  the 
lens.  The  distance  at  which  the  latter  must  be  hold  from  the  paper  in  order  to  ob- 
tain a  sharj^ly  defined  image  corresponds  in  general  to  the  focal  distance,  which  is 
measured  in  centimeters.  Then  it  is  only  necessai-y  to  divide  100  by  this  number 
(100  cm  ^  1  m;  the  lenses  are  numbered  according  to  the  metric  system)  in  order 
to  learn  its  strength  in  diopters.     If  the  image  is  sharply  defined  at  the  distance  of 

100 
5  cm  the  lens  is r=  20   diopters  strength. 


or  both  have  over  4  D  of  myopia  the  pliysician  must  come  closer;  if  either 
cne  or  both  are  quite  hypermetropic  the  distance  must  be  somewhat  greater. 
We  must  proceed  in  a  manner  similar  to  that  employed  in  tlie  use  of  a  micro- 
scope. First  comes  the  gross  presentation  at  the  distances  given  above,  and 
then  comes  the  micrometer  screw,  by  the  movement  of  the  head  of  the  physician 
a  little  backward  and  forward  until  the  image  is  sharply  defined. 

In  high  degrees  of  hypcrmetropia,  like  such  as  are  present  after  removal 
of  the  lens  for  cataract,  the  observer  must  increase  the  distance  quite  a  good 


Fig.  a. 


deal   in  order  to  obtain  a  distinct   image  of  tlie   fundus   (see  Detaclmient   of 
the  Retina,  page  1-52). 

Next  to  faulty  accommodation,  incorrect  distance  is  the  most   important 
cause  of  iiuiistinctness  of  the  image  (see  under  (>)• 


3.  Correct  Accommodation. 

The  image  of  the  fundus  produced  by  the  convex  lens  lies  in  front  of  the 
latter  at  the  distance  of  its  focal  point.  7  cm  in  front  of  it,  at  point  B  in 
Fig.  U.  The  physician  must  focus  his  eye  upon  this  point.  This  is  done 
most  easily  when  the  point  is  at  his  ordinary  reading  distance,  "2.5  to  30  cm, 
and  the  accommodation  used  for  reading  is  called  into  activity.  But  begin- 
ners usually  try  to  see  the  image  in  the  ej'e  of  the  patient,  accommodate 
incorrectly,  and  so  cause  the  image  to  be  indistinct.  An  emmetrope  can 
overcome  this  difficulty  by  substituting  for  the  necessary  accommodation  a 
convex  glass  of  from  2  to  4  D,  preferably  behind  the  mirror.  A  myope  lessens 
his  correcting  glass  by  the  same  amount,  so  that  myopes  of  less  than  4  D 
do  best  without  any  correcting  glass,  while  a  hypermetrope  has  to   increase 


the  strength  of  his  glass.  It  is  well  for  the  {)h_vsieiaii  to  euiaiieipnte  iiiinself 
from  tlie  need  of  tliis  glass  by  prolonged  praetice. 

Anotiier  trick  is  to  have  someone  hold  the  ti|)  of  his  finger  at  the  place 
where  the  image  must  be  formed,  i.e.,  T  em  in  front  of  the  lens;  the  observer 
fixes  his  eyes  on  the  tij)  of  the  finger  and  maintains  iiis  ucconmiodation  when 
it  is   witlulr.iwii. 

A  corollary  to  what  ha.s  been  said  is  tliat  the  observer  must  be  certain 
in  regard  to  his  own  refractive  condition. 


7cm~ 


Z5-30cm. 


Fig.  B. 

4.  The  Question  of  Wearing  Glasses 

during  an  ophthalmoscopic  examination  has  been  answered  by  the  above 
ri'inarks.  As  the  image  lies  in  front  of  him  at  the  distance  of  25  to  30  cm, 
the  ordinary  reading  distance,  the  physician  wears  the  same  glass  that  he 
uses  to  read  witli,  particulaily  if  he  is  presbyopic.  The  most  convenient  way 
is  to  jilace  a  glass  of  the  jjroper  strength  behind  the  mirror. 


5.  Avoidance  of  Reflexes  from  the  Lens  and  Cornea. 

These  reflexes  can  never  be  wholly  avoided,  even  by  the  most  expert.  The 
student  nnist  learn  to  place  them  so  that  they  do  not  fall  directly  on  the 
place  under  observation.  He  may  partially  succeed  in  doing  this  by  moving 
the  lens  a  little  to  the  right  or  left,  so  as  not  to  look  directly  through  its 
center,  or  by  holding  the  lens  in  a  slightly  oblicjue  jjosition.  Much  is  won 
when  he  learns  to  look  past  the  reflexes,  for  the  disturi)ance  they  cause  is 
due  not  only  to  the  fact  that  they  cover  the  image,  but  also  to  the  fact  that 
they  distract  the  attention  and  consequently  excite  a  faulty  acconnnodation 
ill  the  eye  of  the  observer. 

Sometimes  the  reflexes  come  from  other  sources  of  light ;  this  may  be 
guarded  against  by  seeing  that  the  only  light  in  the  room  is  the  one  used 
for  ophthalmoscopy,  and  that  this  is  placed  obliquely  behind  the  patient,  so 
that  the  eye  to  be  examined  is  altogethei-  in  the  shade. 

Finally,  the  lens  itself  must  be  perfectly  clean,  for  a  dirty  lens  increases 
enormously  the  reflexes  that  appear. 


6.  Indistinctness  of  the  Image. 

AfttT  sicrlit   has  huun   caufrlit   of  the  jiapilhi   it  often   appears  to  be  very 
indistinct.     This  may  be  due  to  a  variety  of  causes. 


Cause 

1.  Tlie  jiliysician  or  the  patient 
may  have  high  degree  of  astigmatism, 
or  of  some  other  error  of  refraction. 

2.  The  distance  may  be  incorrect. 

3.  His  accommodation  may  be 
faulty. 

4.  Opacities  may  be  present  in  the 
refractive  media. 

5.  Tlie  indistinctness  may  be  due 
to  disease  of  tlie  optic  nerve,  retina, 
etc. 


Bemcdy 

He  must  therefore  know  the  re- 
fraction of  l)oth  liimself  and  the  pa- 
tient, and  may  need   to  correct  it. 

Given  under  2. 

Given  under  3. 

Therefore  lie  throws  light  into  the 
eye  without  using  a  lens  before  trying 
to  see  the  fundus. 

The  beginner  should  not  make  this 
diagnosis  until  he  is  positive  that  the 
cause  lies  neither  in  himself  nor  in  his 
technique. 


7.  Incompleteness  of  the  Image. 

If  only  a  j)ortion,  Init  not  the  whole,  of  the  papilla  comes  into  view,  the 
examiner  moves  himself  toward  the  side  which  he  wishes  to  see,  wiiile  the 
patient  maintains  his  line  of  regard.  For  example,  if  only  the  left  side  of 
the  papilla  can  be  seen  from  the  standpoint  of  the  observer,  the  latter  moves 
his  head  very  slightly  to  the  right.  Of  course  the  same  result  could  be  obtained 
by  having  the  patient  look  a  little  more  to  the  left,  but  the  obsei'ver  usually 
has  his  own  movements  under  better  control  than  those  of  tiie  patient. 

//,  in  spite  of  (lU  tliis,  the  observer  Jias  not  siiceeeded  in  seeing  tlie  papiUii. 
or  anfi  portion  of  it.  it  is  best  for  him  to  break  off  tite  examination,  to  redireet 
the  patient  how  to  look  (see  under  1),  and  to  try  again. 

8.  The  Investigation  of  the  Macula  is  often  difficult,  even  for  the 
expert,  so  there  should  be  no  iiesitation  to  dilate  tiie  pupil  wlien  it  cannot 
be  seen  clearly,  and  to  examine  the  eye  when  in  a  condition  of  mydriasis.  In 
doing  this  the  rules  should  be  observed  that  are  given  on  page  11. 

The  macula  is  so  placed  that  in  order  to  bring  it  into  view  eitiier  the 
patient  must  look  at  the  aperture  in  the  center  of  the  mirror,  or  the  phvsician 
must  move  his  own  eye  into  the  line  of  vision  of  the  patient,  while  the  latter 
remains  looking  in  the  same  direction  as  during  the  presentation  of  the 
papilla.  It  is  also  possible,  wliile  tile  eyes  retain  tlieir  relative  positions,  for 
the  physician  to  move  the  lens  toward  the  patient's  nose  until  the  macula 
appears  in  its  temporal  margin. 


8 

9.  For  the  Examination  of  the  Periphery,  which  must  ikvui-  be 
omitted,  tlie  piitiout  is  told  to  look  up.  down,  to  the  ri<jlit,  .•uid  to  thu  kft. 
The  fundus  can  be  seen  in  this  way  to  within  .5  mm  of  tin-  miliary  body. 

II.    UPRIGHT    IMAGE 

Tlie  difficulties  in  the  wa^'  of  an  examination  of  the  uprii^ht  imawe  lie  in 
tlie  reiuxation  of  the  accommodation  and  the  management  of  the  light.  The 
following  method  seems  the  best  to  me,  taking  for  an  example  an  examination 
of  the  left  eye.  When  practicable  a  drop  of  a  3  per  cent,  solution  of  cocaine, 
or  of  a  1  per  cent,  solution  of  honiatropine,  should  be  placed  in  the  eye  half 
an  hour  before   the  examination. 

]^  Coca  in.,   hydrochlorat    ().'3        II   Ilomat  ropiii.   hydrobrom.    ...      0.1 

Aqua-  destil ad    10.0  .\(|ua'  destil ad    10.0 

M.  Sig.     One  drop  in  the  eye.  ^M.  Sig.     One  drop  in  the  ej'e. 

Examination  of  the  Left  Eye 

The  light  should  be  plactd  near  the  Kft  side  of  the  ])atient  on  a  level 
with  his  eve.  The  physician  and  the  patient  should  lie  seated  on  a  level,  and 
about  W  cm  a])art.  The  ])atient  .should  be  told  to  fix  his  eyes  on  a  point 
on  the  wall  situated  in  the  prolongation  of  a  line  connecting  his  left  eye 
with  the  left  eve  of  the  physician.  The  latter  places  his  left  hand  on  the 
right  shoulder  of  the  patient,  or  rather  somewhat  about  the  neck,  so  that 
he  can  direct  the  movements  of  the  head  as  desired,  then  takes  the  ophthal- 


FiG.  C. 

moscope  in  his  right  hand,  interposes  the  glass  that  corrects  his  own  refractive 
error  plus  that  of  the  patient,  approximately  at  least,  holds  it  before  his 
left  eye,  throws  the  light  into  the  eye  to  be  examined,  and  sees  the  red  illu- 
mination of  the  pupil.  '  Now  he  slowly  approaches  the  patient,  whose  head 
he   presses   a  little  forward  at  the   same  time,   ever  keeping  in   view  the   red 


9 

illumination  of  the  pupil  and  making  it  bright  again,  whenever  it  threatens 
to  become  indistinct,  by  little  rotations  of  the  mirror. 

Thus  the  eye  of  the  physician  and  that  of  the  patient  approach  each 
other  until  they  are  only  1  cm  apart.  If  the  observer  has  not  lost  the  light 
on  the  way,  the  papilla  suddenly  appears  before  him  in  its  perfect  beauty. 
If  he  has  lost  the  light  he  draws  quietly  back  from  the  j)atient  and  repeats 
the  same  maneuver.  If  it  is  lost  again  at  the  same  place,  the  cause  may  be 
either  an  insufficient  rotation  of  the  mirror,  a  lock  of  hair,  or  tlie  position 
of  the  light.  He  corrects  the  fault,  whatever  it  may  be,  and  begins  again. 
Success  is  usually  obtained  after  a  few  efforts.  If  the  image  is  not  (juite 
distinct  the  lenses  in  the  ophthalmoscope  are  slowly  changed  for  stronger  or 
weaker  ones,  while  the  observer  watches  until  a  sharply  defined  image  of  the 
papilla  is  obtained.  The  best  way  to  do  this  is  to  look  constantly  at  a  certain 
blood  vessel,  and  so  to  determine  the  correction.  If  the  entire  papilla  is  not 
seen,  or  if  the  physician  wishes  to  look  at  another  part  of  the  fundus  than 
that  directly  before  him,  he  moves  his  head  in  the  direction  opposite  to  that 
in  which  the  part  lies  which  he  wants  to  see.  In  other  words,  he  looks  at  the 
fundus  through  the  pupil  just  as  he  would  look  into  a  room  through  a  key- 
hole; when  he  wishes  to  see  the  right  side  he  moves  his  head  to  the  left,  and 
vice  versa.  The  patient  should  continue  throughout  to  look  quietly  in  the 
same  direction. 

The  right  eye  should  always  be  examined  with  the  right  eye,  the  left 
with  the  left,  and  the  light  should  always  be  on  the  same  side  of  the  patient 
as  the  eve  that  is  being  examined. 


DETERMINATION  OF  DIFFERENCES  OF  LEVEL  IN  THE 

FUNDUS 

AVe  perceive  depth  in  ordinary  life  bv  means  of  binocular  vision,  but,  as 
we  can  see  with  only  one  eye  when  we  use  the  ophthalmoscope,  this  kind  of 
perception  of  depth  is  out  of  the  question.  Still  we  can  distinctly  recognize 
differences  of  level  in  various  ways. 

1.  By  the  so-called  Parallactic  Displacement.  This  is  noted  during 
the  examination  of  the  inverted  image.  If  the  convex  lens  is  moved  back  and 
forth  a  little,  the  details  of  the  fundus  seem  to  move  against  one  another  if 
differences  in  level  are  present ;  the  parts  nearer  the  observer  seem  to  be 
displaced  more,  or  to  move  more  rapidly,  than  those  situated  farther  away. 
When  a  glaucomatous  excavation,  for  examjile.  is  examined  in  this  way  the 
impression  is  given  that  its  margins  are  slid  forward  over  its  base. 

2.  By  the  Perspective  Displacemsnt.  When  the  observer  moves  a 
little  from  side  to  side  during  an  examination  of  the  u{)right  image,  the 
impression  is  given  that  the  nearer  places  move  in  the  opposite,  while  those 
farther  awav  move  in  the  same  direction. 


10 

3.  By  tlie  Determination  of  the  Refraction  <  f  the  p.uts  that  come 
into  question.  Tins  also  is  ddiu'  in  llir  rxaiiiiiial  ion  of  tiii'  iiprifjlit  iniafrc. 
A  hvi)crnict  ropic  eye  is  too  short,  in  comparison  with  an  eimnetropie,  i.e., 
its  retina  is  nearer  to  tlie  eye  of  tlie  observer  than  that  of  an  emmetropic 
eye,  all  other  conditions  Ijeincf  the  same.  Hence,  ^^  hen  in  an  otherwise  emme- 
tropic eye  a  certain  j)ai't,  for  exanipK-  a  choked  disi',  is  (rreatly  elevated  so 
as  to  lir  ch)scr  to  the  eve  of  the  ohsrrvcr,  such  a  part  will  l)e  ii vpci'inctro])ic 
and  form  a  contrast  witii  its  emmetropic  surroundings.  If  the  eye  is  myopic 
the  elevated  part  will  he  less  so  tlian  tiie  rest  of  tlie  fundus.  In  evei-y  case 
the  elevated  |)ai-t  has  a  lower  deiirie  of  refraction  than  those  portions  that 
lie  farther  li.'ck,  and  vice  versa.  A  dift'ei-ence  in  level  can  le  calculated  in 
millimeters  from  the  difference  in  nfraction,  for  a  difference  of  refraction 
of  .'J  1)  corresponds  to  an  elevation  or  depression  of  1  nnn.  F{)r  example,  if 
the  retina  of  an  eye  is  ennuetropic  and  the  jjajiilla  is  liypernietroj)ic  .'5  1), 
we  know  that  the  papilla  is  raised  1   mm  aljo\e  the  retina. 

4.  When  the  dift'erence  of  level  is  very  great,  as  is  the  case  in  a  bullous 
detachment  of  the  retina,  the  different  parts  of  ti'e  fundus  can  be  seen  at 
varying  distances.  It  has  been  mentioned  that  in  high  hy|)ermi  tropia,  as  in 
aphakia,  we  have  to  lean  far  back  in  order  to  see  the  fundus  distinctly  by 
the  indirect  method.  This  is  the  case  to  a  much  greater  degree  with  the 
detached  j)orti(;n  of  the  I'etina:  whiK-  the  parts  that  are  not  detached  can  be 
seen  at  the  normal  distance,  we  have  to  lean  very  far  back  in  order  to  sec 
those  that  are  detached. 

5.  Great  differences  of  level,  as  in  detachment  of  the  retina,  can  often 
be  percei\X'd  better  by  sim})le  illumination  than  bv  either  the  direct  oi'  the 
uidirect  method.  I>ight  is  thrown  into  the  eye,  and  then  the  normal  portions 
a))pcar  to  be  bright  while  the  detached  parts  are  dark,  or  perhaps  the  detached 
bulla  can  be  distinctly  seen,  especially  if  the  observer  draws  rather  near  to 
the  eye. 

We  indicate  the  Place  and  Size  of  a  Lesion  in  the  Fundus  by 
reference  to  the  papilla  and  its  diameter,  which  i>  1..")  nnn.  b'or  example, 
we  say  that  the  size  of  a  lesion  is  ^  ••  a  papillarv  diameter,  i.e.,  that  its  diam- 
eter is  0.75  nun,  or  that  it  lies  2  papillary  diameters  from  the  temporal 
margin  of  the  disc  of  the  optic  nerve,  i.e.,  3  mm  distant. 


THE  DILATATION   OF  THE   PUPIL  FOR  THE  PURPOSE 
OF   AN   OPHTHALMOSCOPIC    EXAMINATION 

is,  under  certain  precautions,  an  absolutely  harmless  procedure,  and  it  is  to 
be  recommended  whenever  the  examination  is  rendered  difficult  by  a  small 
pupil.  It  is  better  to  make  an  exact  diagnosis  with  a  dilated  pupil  than  to 
make  an  incorrect  or  incomplete  one  because  the  pupil  is  too  small.  It  is 
no  confession  of  incompetence  or  ignorance.      It  is  often  almost  essential   for 


11 

the  use  of  the  direct  method,  or  tlie  examiiiiition  of  the  macula.  The  only 
thin^  necessary  is  that  certain  precautions  he  ohservcd,  and  these  are: 

1-  Never  use  atropine  to  dihite  the  ])uj)ils  for  this  purpose,  because  it 
renders  paretic  not  only  the  sphincter  pupiUa',  but  also  the  acconnnodation 
for  about  8  davs,  so  that  the  patient  is  unable  to  read  or  write  for  a  week. 
What  that  means  is  readily  appreciated  by  a  pliysician  who  has  once  instilled 
atropine  into  his  own  eyes  by  way  of  experiment. 

2.  Care  must  be  exercised  in  the  case  of  old  people,  and  if  there  is  any 
suspicion  of  glaucoma.  In  the  latter  case  it  is  best  not  to  use  any  mydriatic 
at  all ;  it  is  often  superfluous,  as  patients  with  glaucoma  usually  have  pupils 
that  are  somewhat  dilated  and  react  badly  to  light.  Not  more  than  one 
drop  of  the  mydriatic  sliould  he  placed  in  the  ej'e  of  an  old  person. 

The  most  suitable  mydriatics  are: 

It  Homatropin.  hych'obroni.  .  .  .      0.1       1{  Cocain.  hydrochlor 0.3 

Aqu;e  destil ad   10.0  Aqua-  destil ad   10.0 

!M.  Sig.     One  or  two  drops  to  M.  Sig.     One  drop  to  dilate  the 

dilate  the  pupil.  pupil. 

XoTK. — Not  more  tjian  a  single  drop  of  cocaine  should  be  used,  because 
an  exfoliation  of  the  epithelium  of  the  cornea  may  readih'  be  induced  by  the 
application  of  many  drops ;  and.  while  this  is  fairly  harmless,  it  interferes 
with  the  view  into  the  e3-e.  Two,  or  even  three,  drops  of  homatropine  may 
readily  be  used,  except  in  cases  of  glaucoma  and  in  old  people.  The  method 
of  instilling  the  drops  is  to  draw  down  the  lower  lid  with  the  forefinger  of 
the  left  hand  and  to  allow  one  drop  of  the  solution  to  fall  gently  upon  the 
inner  surface  of  the  lid  from  a  dropper  held  in  the  right  hand.  It  is  of  no 
use  to  instill  a  large  number  of  drops,  as  they  inmiediately  escape.  The 
patient  is  sent  back  into  the  waiting  room  and  half  an  hour  later  we  see 
if  the  pupil  is  dilated.  Usually  it  is ;  if  it  is  not,  another  drop  is  instilled 
and  the  eye  is  seen  again  15  minutes  later.  Tlie  mydriasis  begins  after  about 
10  minutes  and  reaches  its  acme  on  the  average  in  half  an  hour.  Four  or 
five  hours  later  the  pupil  has  usvially  regained  its  normal  size.  The  accom- 
panying disturbance  of  the  accommodation  is  therefore  comparatively  slight, 
especially  when  cocaine  is  used. 


The  Normal  Papilla  and  the  Normal  Fundus 


Anatomical    Review 

A  brief  review  of  the  anatomy  is  essential  in  order  to  understand  the 
ophthalmoscopic  picture  of  the  papilla  of  the  optic  nerve.  This  nerve  enters 
the  eyeball  througli  the  lamina  cribrosa  of  the  sclera,  to  the  inner  side  of 
and  a  little  below  the  posterior  end  of  the  optic  axis,  and  there  forms  the 
papilla. 

The  optic  nerve  is  to  be  considered  as  a  portion  of  the  brain  that  has 
been  projected  forward,  and,  like  the  latter,  it  is  enveloped  in  3  sheaths,  the 
dural,  arachnoidal,  and  pial  membranes,  the  interspaces  of  which  correspond 
to  those  of  the  brain  and  are  furtlicrmore  connected  directly  with  the  lateral 
ventricles.  This  fact  explains  how  it  is  that  an  increase  of  pressure  in  the 
brain  is  transmitted  into  the  optic  nerve  to  produce  a  choked  disc.  The  two 
outer  sheaths  pass  over  into  the  two  outer  layers  of  the  sclera,  while  the 
inner  one  enters  its  innermost  lamella,  which  forms  the  lamina  cribrosa,  and  is 
connected  with  the  cjiorioid.  A  number  of  vessels,  which  surround  the  optic 
nerve  and  are  fed  by  the  posterior  short  ciliary  arteries,  may  be  seen  on 
transverse  section  in  the  neighborhood  of  the  place  where  this  change  occurs. 
These  vessels  form  Zinn's,  or  the  sclerotic,  vascular  plexus.  As  this  plexus 
gives  off  branches  to  the  optic  nerve  a  connection  is  formed  between  the  vas- 
cular systems  of  the  retina  and  the  chorioid,  but  this  union  is  of  no  practical 
importance. 

Two  segments,  the  anterior  and  the  posterior,  need  to  be  differentiated 
in  the  intraorbital  portion  of  the  optic  nerve,  because  of  the  vascular  supply. 
The  anterior  segment  is  supplied  by  the  central  artery  and  vein  of  the  retina, 
which  enter  it  in  the  lower  medial  quadrant,  10  or  12  mm  from  tiie  eyeball, 
and  then  run  axially  in  the  nerve.  The  artery  comes  from  the  trunk,  or  a 
branch,  of  the  ophthalmic  artery,  which  in  turn  is  a  branch  of  the  internal 
carotid.  The  vein  empties  into  the  cavernous  sinus,  or  into  tlic  superior 
facial  vein,  and  has  numerous  anastomoses  with  other  veins  in  the  orbit. 

The  posterior  segment  receives  its  blood  supply  from  a  long,  recurrent 
branch  of  the  central  artery  of  the  retina  and  other  branches  of  the  ophthal- 
mic artery,  and  discharges  its  blood  into  the  cavernous  sinus. 

The  optic  nerve  is  circular  on  section  ni  its  orbital  portion  and  is 
about  4  mm  thick.  It  is  composed  of  nerve  fibers  and  connective  tissue.  The 
nerve  fibers  form  bundles  that  run  parallel  to  one  another,  and  are  interlaced 
together  by  an  interchange  of  fibers,  the  number  of  wliicli  lias  been  estimated 

15 


16 

at  half  a  million.  The  nerve  fibers  have  a  medullary  sheath,  but  no  sheatli 
of  Srincinni.  ami  a  supporting-  siibst.uicc  composed  of  neuro^-jia  tissue  lies 
between  tiiem.  Tlie  pial  siuatli,  uliieli  is  closely  adherent  to  the  surface  of 
tlie  lU'rve,  sends  numei'ous  t i-aiiecul.-i'  and  srpla  into  it,  wliiTe  tliev  .join  to 
form  a  ni'twork,  and  to  invelopi'  the  bundles  of  nerve  fibcis.  \\'itliin  these 
are  to  be  found  the  lymphatic  and  blood  vessels. 


" 

^gyi^^.j^r  j^ry^^ 

4. 

i 

^-  :                 '      f 

f 


Fit;.   D. — ilicr(ise(i|iie    Seelicni    lhroiii;li   a    Xornial    Ojitie   Nerv'e. 

The  lumina  of  vessels  which  form  part  of  Zinn's  vascular  ]]le.xus  can  l)e  seen  at  the 
place  where  the  dural  sheath  bends  over  to  join  the  sclera.  The  papilla  is  a  flat 
surface  in  the  drawing-,  with  no  marked  excavation. 


The  caliber  of  the  fibers  of  the  0[)tic  nerve  varies;  the  average  is  about 
2  \f:  The  smallest  are  those  of  the  papillomacular  bundle,  which  supply  the 
macula  and  form  the  medium  oi  tlie  finest  vision.  This  bundle  is  of  a  longi- 
tudinally oval  form,  situated  in  the  center  of  the  nerve  at  the  optic  foramen, 
from  which  j)oint  it  gradually  approaches  its  temporal  side,  until  at  tiie 
place  of  entrance  of  the  central  vessels  it  lies  wholly  in  its  temporal  margin 
and  occupies  the  lower,  outer  sector  of  the  disk  in  the  form  of  a  wedge  with 
its  apex  inward. 

At  the  level  of  the  inner  surface  of  the  sclera  are  numerous  fibers  of  ccm- 
nective  tissue  cutting  transversely  through  the  nerve,  whicli,  together  wltli 
other  fibers  of  connective  tissue  from  the  sclera  and  chorioid,  form  the  lamina 
cribrosa,  through  tlie  numerous  meshes  of  which  passes  the  optic  nerve, 
which  at  this  point  is  1.6  mm  thick.  The  diminution  of  its  diameter  is  due  to 
its  loss  of  the  medullary  sheaths  that  are  retained  as  far  as  the  posterior  third 
of  the  sclera,  and  are  lost  just  before  the  nerve  reaches  the  lamina  cribrosa. 
This  loss  not  only  diminishes  the  calibi-r,  but  also  causes  a  change  in  its 
color;  while  the  medullated  fibers  appear  white,  the  nonmedullated  look  rather 
grayish. 

The  fibers  of  the  optic  nerve  bend  outward  in  the  papilla  and  arc  dis- 
tributed in  the  layer  of  nerve  fibers  of  the  retina  (see  page  112). 


17 

A.  THE  OPHTHALMOSCOPIC  PICTURE  OF  THE  NORMAL 

PAPILLA 

The  followinn;  points  luive  to  Ik-  noted,  one  after  another,  in  a  systematic 
examination : 

1.  Form  and  size. 

2.  Color. 

3.  Margins. 

4.  Conditions  of  level,  excavation  or  protrusion. 

5.  Vessels. 

1.  The  Form  of  the  normal  papilla  is  usually  round,  or  slio-htly  oval 
vertically.  Ia'ss  often  it  appears  to  be  horizontally,  or  obliquely  oval,  a 
peculiarity  which  does  not  usually  correspond  to  an  actual  anatomical  con- 
dition, but  is  produced  by  an  astigmatism  of  the  cornea. 

The  variations  in  size  are  also  only  apparent  as  a  rule;  in  hypermetropia 
the  papilla  seems  to  be  larger,  in  myopia  smaller,  when  examined  by  the 
indirect  method,  the  reverse  when  seen  by  the  direct.  At  the  same  time 
true  differences  in  size  are  met  with;  sometimes  the  papilla  is  unusually  small 
in  the  "little"  hypermetropic  eyes   (see  under   Pseudoneuritis). 

Attention  may  be  called  here  to  a  mistake  often  made  by  beginners,  who 
sometimes  include  a  circular  staphyloma,  in  congenital  myopia,  with  the 
nerve  and  are  led  to  think  that  the  papilla  is  enlarged. 

The  color  of  the  papilla  is  a  delicate  red  which  might  aptly  be  compared 
to  that  of  a  peach  blossom.  The  temporal  side  (upright  image)  is  usually 
a  little  brighter  than  the  nasal.  In  a  large  number  of  cases  a  specially 
bright  spot  is  to  be  seen  in,  or  a  little  to  one  side  of,  the  center,  which  corre- 
sponds to  the  excavation  about  to  be  described. 

2.  The  Color  results  from  the  combination  of  that  of  the  lamina  cribrosa 
and  its  meshes  with  that  of  the  almost  transparent  fibers  of  the  optic  nerve. 
The  former  is  almost  white,  except  for  the  apertures,  which  have  a  gray  appear- 
ance, while  the  optic  nerve  fibers,  which  are  slightly  gray,  seem  reddish  from 
the  presence  in  them  of  numerous  capillaries.  The  observer  sees  through 
the  almost  transparent  fibers  to  the  lamina.  At  the  places  where  the  fibers 
are  particularly'  well  developed  and  densely  packed,  for  example  at  the 
nasal  margin  in  the  upright  image,  the  paj)illa  appears  redder  tlian  where 
they  are  less  in  number,  as  at  the  temporal  margin,  over  which  pass  the  few 
and  delicate  fibers  that   supply  the  macula   (see  Papillomacular  bundle). 

The  brighter  color  of  the  temporal  side  is  not,  therefore,  an  indication 
of  atrophy;  this  is  indicated  by  a  true  white  color. 

On  the  contrary,  those  places  in  which  the  optic  nerve  fibers  are  almost 
wholly  wanting,  as  at  the  bottom  of  an  excavation,  must  normally  be  white, 
the  color  of  the  lamina  cribrosa. 

The  color  of  the   p;i})illa   is   also  influenced  by   its  environment.      If  this 


18 

is  very  dark,  as  in  brunettes,  the  optic  nerve  will  seem  to  he  particularly 
bright  from  contrast,  and,  on  the  other  hand,  it  looks  redder  when  the  fundus 
is  particularly  pale. 

The  nature  of  the  light,  whether  gas  or  electric,  likewise  exerts  a  certain 
influence,  as  the  papilla  appears  to  be  paler  or  redder  in  proportion  to  the 
number  of  red  rays  it  contains. 

It  is  also  affected  by  age,  as  in  youth  the  red  prevails  strongly,  while  a 
yellowish  tone  is  apt  to  be  acquired  in  old  age.  According  to  Elschnig,  the 
size  of  the  papilla,  which  is  not  always  constant,  has  an  influence  on  its  color. 
As  it  must  be  supposed  that  there  cannot  be  any  excessive  difference  in  the 
number  of  nerve  fibers  that  reach  the  normal  eye,  small  papillie  are  generally 
redder  than  large  ones,  because  of  the  relatively  denser  layer  of  bundles  of 
nerve  fibers  with  the  capillaries  between  them. 

3.  The  Margins  of  the  normal  papilla  are  sharply  defined.  Special 
marginal  rings  are  frequently  present,  one  \jhite,  the  so-called  connect ivi' 
tissue  ring,  or  scleral  ring,  and  one  black,  the  so-called  pigment  ring,  which 
is  sometimes  termed  erroneously  the  chorioidal  ring. 

The  white  ring  may  be  due  to  two  different  anatomical  conditions:  it  may 
be  either  a  true  connective  tissue  ring,  separating  the  chorioid  from  the 
sheath  of  the  optic  nerve,  or  the  sclera  itself  covered  with  rudimentary 
chorioiil  and  marginal  tissue  (see  Fig.  1). 

The  black  ring  is  produced  when  the  pigment  layer  of  the  retina  in  the 
neighborhood  of  the  optic  nerve  is  particularly  thick  and  this  thickening 
stands  out  prominently.  If  this  ring  lies  close  to  the  papilla  a  connective 
tissue  ring  cannot  be  seen,  but  otherwise  there  may  be  seen  first  a  connective 
tissue  ring  and  then  a  ring  of  pigment.  It  is  only  in  exceptional  cases  that 
these  circles  are  complete;  segments  only  are  visible,  as  a  rule,  and  these 
are  usually  on  the  temporal  side;  frequently  there  is  an  accumulation  of 
pigment  instead  of  a  black  line,  and  sometimes  one  or  both  of  the  rings 
are  entirely  absent. 

Sometimes  the  chorioid,  retina  and  sclera  are  pushed  over  the  nasal  mar- 
gin of  the  papilla,  so  that  this  appears  thick  and  indistinct  (see  Fig.  I  iti 
the  text  and  Fig.  5).  This  happens  more  often  in  myopic  th;in  in  emme- 
tropic eyes.  The  margin  of  the  papilla,  that  is,  the  portion  of  the  optic 
nerve  that  is  covered,  shines  quite  weakly  through  the  tissue  as  a  yellow 
crescent,  the  supertraction  crescent  (see  Fig.  I  in  the  text).  The  margin 
is  more  distinct  on  the  temporal  side  than  on  the  others  for  the  reasons 
already  mentioned. 

Age  again  plays  a  certain  part,  for  the  zone  of  pigment  is  usually  devel- 
oped considerably  more  in  infants  than  in  adults. 

4.  Excavation  of  the  Papilla. 

The  name  papilla  dates  back  to  the  time  when  it  was  thought  to  be  an 
elevation  at  the  entrance  of  the  optic  nerve.    This  was  an  erroneous  anatomical 


19 

idea;  tlio  p<ii)illu  rises  iihovo  the  level  of  the  surrouiuling  retina  only  in 
exceptional  cases,  as  a  rule  it  is  of  the  same  lu^itrlit. 

Two  types  need  to  be  differentiated: 

(«)  The  flat  papilla,  in  which  tiie  spreading  out  of  the  tihei-s  of  the  optic 
nerve  takes  place  wholly  on  a  level  with  the  retina.  Tlu'  coloi-  of  such  a 
papilla  is  almost  uniformly  reddish,  thei-e  is  scarcely  any  difference  in  color 
between  the  nasal  and  temporal  portions,  and  the  white  spot,  which  indicates 
the  excavation  in  the  other  type,  is  nearly  absent  (see  Fig.  D  in  the  text). 


Fir:.  E. — Small  Excavation  in  the  Temporal  Part  of  the  Papilln. 

The  margins  of  the  papilla   are  slightly  elevated   and  surround   a   funuelshaped 

excavation. 

(b)  The  excavated  papilla.  The  excavation  is  due  to  the  fact  that  the 
fibers  of  the  optic  nerve  do  not  completely  fill  out  the  hole  in  the  chorioid; 
they  cling  to  the  wall  of  the  sclerotico-chorioidal  canal  and  leave  in  the 
center,  as  they  swell  out  like  a  fountain,  a  larger  or  smaller  funuelshaped 
or  cupshaped  cavity  below  the  level  of  the  surrounding  tissue.  The  presence 
of  this  cup  is  recognized  ophthalnioscopically  from  the  fact  that  the  reddish 
color  changes  either  suddenly  or  gradually  to  a  whitish,  or  to  white. 

The  size  of  the  excavation  varies  a  great  deal.  It  may  occupy  only  a 
very  small  part  of  the  papilla,  or  it  may  be  so  large  as  to  reduce  the  normally 
colored  portion  to  a  narrow  circle  or  crescent,  but  a  colored  zone  always 
lies  between  it  and  the  adjacent  retina  (see  Fig.  X  in  the  text  and  Fig.  15)- 

The  transition  from  the  tissue  proper  of  the  papilla  to  the  excavation 
may  be  either  gradual  or  abrupt.  This  is  to  be  perceived  from  the  behavior 
of  the  vessels ;  in  the  former  case  they  pass  without  visible  bending  into  the 
white  place,  in  the  latter  they  suddenly  bend  like  hooks.  While  they  may 
be  seen  clearly  and  distinctly  from  the  margin  of  the  })apilla  to  that  of  the 
excavation,  they  suddenly  become  indistinct  at  this  point  and  a])pear  as 
bright,  indistinct  bands  at  the  bottom  of  the  excavation,  or  become  more  or 
less  invisible.  If  they  plunge  downward  very  abruptly  they  have  a  markedly 
dark  color  at  the   edije   of  the  excavation,   and   sinndate  there   a   verv   dark 


20 

swelling.  Hence  it  is  that  the  light  streak,  visible  everywhere  else,  is  absent 
at  the  place  where  the  vessel  bends  (see  page  105  and  later);  perhaps  also 
because  at  this  place  the  vessel  is  seen,  as  it  were,  end  on,  as  it  j)lunges 
downward. 

The  reason  why  the  vessels   in   tlie  floor  of   tlie  excavation  are  sometimes 
seen  either   not   at   all,  or   to   follow   different   courses,   is   that   they   do    not 


Fig.  F. — Schematic  Drawing  of  the  Fundus,  Upright  Image. 


plunge  straight  down  from  the  margin  of  the  excavation,  but  bend  to  one 
side;  in  this  case  the  apparent  end  of  the  vessel  is  apt  to  be  pointed,  like  the 
beak  of  a  bird  (see  Fig.  M). 

The  excavation  maj'  be  1  mm  deep.  As  1  mm  ^  3  D  (see  page  10),  a 
change  must  be  made  in  the  lenses  of  the  ophthalmoscope  in  order  to  bring 
into  focus  the  vessels  at  its  bottom  when  using  the  direct  method.  If  both 
the  observer   and  the   patient   are   ennnetroj)ic,   a  — 3  D   lens   must   be  inter- 


21 

posed  to  enable  the   former  to   see    tlieiii   clearly.      Parallactic   displacements 
also  are  visible  when  the  depth  is  sufficient. 

The  position  of  the  excavation   is  usually  central;  it  frequently  extends 
into  the  temporal  portion,  rarely  into  the  lower.     Sometimes  it  reaches  to  the 


Fio.  G.— fSchematic.) 

This  figure  is  intended  to  show  in  what  way  the  great  variety  in  the  courses  of  the 
retinal  vessels  comes  to  take  place.  If  the  vessel  divides  within  the  optic  nerve  it 
is  not  the  trunk,  but  the  branches  that  emerge  from  the  papilla. 


temporal  margin,  hut  there  it  slopes  away  gradually.  Ever//  abrupt  cxcnva- 
tiori  that  extends  to  the  margin,  of  the  papUla  U  to  hf  conaulereJ  pathological. 
The  bottom  of  the  excavation  is  not  uniformly  white:  usually  the  central 
portion  alone  is  of  this  color,  while  the  peripheral  parts  have  a  reddish  gray 
tone.  Dark  points  may  also  be  seen  in  the  white  itself;  these  are  caused  by 
the  meshes  of  the  lamina  cribrosa. 


5.  The  Vessels. 

Tlic  artcrv  ami  vein  divide,  to  draw  a  very  schematic  pictui'C,  sending  a 
branch  upward  and  anotlier  downward,  the  superior  and  inferior  artery  and 
vein  of  tlie  papilla,  and  lacii  of  tlusi'  sul)(li\i(k'  into  two  branclus,  the  superior 
temporal  and  nasal  arteries  antl  veins  and  the  inferior  temporal  and  nasal 
arteries  and  veins.  Each  of  these  divide  again  into  two  branches,  from 
which  in  turn  spring  two  smaller  ones,  and  so  on.  No  ana'^tomoses  arc 
present  But  such  a  regular  subdivision  as  this  schematic  drawing  is  actually 
seen  only  in  extremely  rare  cases — at  least,  I  have  not  seen  a  single  one  in 
the  manv  thousands  of  eyes  that  I  have  examineil  ophthalmoscopically  for 
the  purpose  of  ri'pi-dduction  in  this  atlas — for  the  subdivisions  are  not  sym- 
metrical. Sometimes  the  vessel  divides  within  the  optic  nerve,  and  then 
we  see  not  the  trunk,  but  the  two  principal  branches  coming  out  of  the  papilla ; 
perhaps  one  of  these  has  already  divided  so  that  apparently  3  vessels  emerge 
from  the  papilla.  In  at  least  the  great  majority  of  cases  the  4  chief 
branches  can  be  differentiated  as  such.  It  is  a  matter  of  importance  to  know 
this  fact,  because  it  may  hapj)en  in  certain  diseases  that  the  vessels  atrophy 
until  they  are  invisible,  so  that  only  from  their  entire  number  can  the  absence- 
of  a  vessel  be  disclosed. 

Attempts  have  been  made  to  utilize  this  condition,  which  is  not  regular, 
but  individual  to  everj'  man,  according  to  BertiUon's  system  for  the  purpose 
of  identification,  but  they  do  not  seem  to  have  been  successful  as  yet. 

The  vessels  of  the  macula  come,  as  a  rule,  from  the  superior  and  inferior 
temporal  arteries  and  veins,  which  are  usually  larger  than  the  corresponding 
nasal  branches,  but  they  frequently  arise  directly  from  the  common  trunk, 
and  in  manv  cases  from  the  system  of  ciliary  vessels  (see  under  Cilioretinal 
vessels ) . 

The  arteries  and  veins  can  l)e  distinguished  apart  easily. 

The  arteries  are  more  slender  than  tlie  veins,  are  of  only  about  two  thirds 
the  size,  follow  more  direct  courses,  and  are  sharper  in  their  outline.  They 
are  bright  red  and  have  distinct  reflexes,  the  breadth  of  which  is  about  one 
quarter  the  diameter  of  the  vessel.  The  veins  are  wine  red  and  have  light 
streaks  which  are  considerabh-  narrower,  one  fourteenth  of  the  diameter  of 
the  vessel,  and  arc  by  no  means  so  distinct  as  those  on  the  arteries.  This 
light  reflex  probably  comes  from  the  surface  of  the  blood  column,  rather 
than  from  that  of  the  vessel  itself.  The  wall  of  the  vessel  is  perfectly  trans- 
parent and  is  perceptible  only  under  pathological  conditions. 

Arteries  and  veins  frequently  cross,  but  no  regidarity  can  be  observed 
as  to  wjiich  of  the  two  is  the  upper  and  which  the  lower,  although  wherever 
two  vessels  cross  one  is  always  an  artery  and  the  other  a  vein.  Branches  of 
the  same  kind  of  vessel  never  cross,  a  fact  that  can  often  be  utilized  to  deter- 
mine the  nature  of  a  vessel  which  cannot  be  seen  distinctly. 


Venous  Pulse. 

No  pulsation  can  be  seen  in  the  arteries  under  normal  conditions,  while, 
on  the  contrary,  the  venous  pulse  is  a  phenomenon  that  can  he  observed  in 
most  men,  though  it  is  ordinarily  not  very  marked.  It  is  to  be  seen  only, 
in  the  principal  venous  trunks  which  lie  on  the  papilla,  and  appears  there 
most  distinctly  in  the  veins  that  are  flattened  to  the  greatest  degree,  or 
seem  to  end  in  a  point  on  the  papilla,  or  in  those  that  bend  at  a  right  angle 
and  form  a  dark  knee  at  the  place  where  they  bend.  In  an  abrupt  excavation 
of  the  optic  nerve  the  pulsation  can  be  seen  best  in  the  veins  that  bend  over 
the  margin  of  the  cup  at  an  acute  angle.  Only  one  venous  trunk  pulsates, 
as  a  rule.  The  contraction  and  paleness  of  the  vein  begins  just  before  the 
beat  of  the  radial  pulse,  extends  from  the  center  toward  the  periphery,  but 
rarely  passes  over  the  margin  of  the  papilla.  Inuncdiately  after  the  radial 
pulse  comes  the  dilatation  and  filling  of  the  vessel  from  the  periphery  toward 
the  center. 

The  way  in  which  the  venous  pulse  is  brought  about  is  explained  in  a 
variety  of  ways.  One  theory  is  that  it  is  a  negative  pulse  caused  by  the 
activity  of  the  right  ventricle  and  auricle  of  the  heart ;  another  is  that  it  is 
caused  by  the  continuous  transmission  of  the  pulse  wave  from  the  arteries 
through  the  capillaries  into  the  veins,  the  possibility  of  such  an  occurrence 
being  provided  for  by  the  comparatively  high  extravascular,  i.e.,  intraocular, 
pressure.  A  third  theory  is  that  an  elevation  of  the  intraocular  pressure  is 
created  by  the  arterial  wave  of  blood,  which  compresses  the  soft-walled  veins, 
and  then,  at  the  instant  when  the  intraocular  tension  falls,  synchronouslj' 
with  the  cessation  of  the  arterial  wave  of  blood,  the  veins  refill. 

A  spontaneous  arterial  pulse  must  always  be  considered  pathological. 

If  the  venous  pulse  is  not  visible  otherwise,  it  can  be  produced  by  making 
a  slight  pressure  on  the  eyeball.  Greater  pressure  may  excite  a  lively 
arterial  pulse. 

Vascular  anomalies  which  are  to  be  looked  upon  as  normal  are: 

1.  The  Cilioretinal  Vessels. 

These  emerge  in  the  form  of  hooks  at  the  periphery  of  the  papilla,  or  in 
the  region  of  the  connective  tissue  ring,  and  pass  into  the  retina  like  the  other 
vessels.  They  arise  from  the  ciliary  arteries,  Zinii's  vascular  plexus,  and 
thence  have  derived  the  name  of  cilioretinal  vessels.  They  are  almost  all 
arteries;  it  is  exceptional  to  meet  with  a  vein.  According  to  Elschnig  thej'  can 
be  seen  in  everj'  seventh  eye. 

2.  The  Opticociliary  Vessels. 

These  are  branches  of  the  central  vessels  which  pass  into  the  vascular  sys- 
tem of  the  chorioid  without  touching  the  retina.  They  are  very  rarely  to 
be  found  in  normal  eyes  but  are  more  common,  as  newly  formed  vessels,  in 
pathological  conditions,  such  as  glaucoma,  choked  disk,  and  wounds. 


B.  THE  FUNDUS   OCULI. 

The  color  of  the  fundus  is  greatly  influenced  l)v  tlie  color  and  density 
of  the  pipiient  ;  the  color  of  the  hlood  vessels  in  the  ehorioid  is  of  less  im- 
portance.    The  visual  purple  can  in  no  way  exert  any  influence;  although  its 


Fig.  H. — Distribution  of  Pigment. 
The  retina  (above)  terminates  ne.\t  to  the  ehorioid  with  the  layer  of  pigment  epithe- 
lium. If  this  layer  is  very  dense  nothing  can  be  seen  of  the  ehorioid,  and  we 
have  the  uniform,  stippled  fundus.  In  the  ehorioid  the  pigment  is  situated 
chiefly  between  the  vessels;  if  the  layer  of  pigment  epithelium  is  not  very  dense 
the  chorioidal  pigment  can  be  seen,  and  we  have  a  tesselated  fundus.  If  the 
chorioidal  pigment  is  also  wanting  the  fundus  is  albinotic. 

name  might  lead  one  to  suppose  it  could,  for  it  is  found  only  in  eyes  adapted 
to  the  dark  and  is  transformed  in  the  light  into  "visual  white." 

Pigment  (see  Fig.  H)   is  found 

(a)   in  the  layer  of  pigment  epithelium  of  the  retina,  and 

{}>)    in  the  intervascular  spaces  of  the  ehorioid. 

We  distinguish,  according  to  the  quantity  and  distribution  of  the  pig- 
ment in  these  two  membranes, 

Three  Types  of  the  Normal  Fundus. 

1.  The  Uniform,  Sfippki]  Fundus  (Fig.  1). 

The  uniform  aj)pearance  of  this  type  of  fundus  is  brought  about  by  the 
fact  tiiat  the  layer  of  pigment  epithelium  contains  so  nuich  and  such  dense 
pigment  that  the  ehorioid  beneath  it  is  completely  hidden  from  the  eye  of  the 
observer.  The  tone  of  color  is  red,  brown  red,  or  black  brown,  according 
to  tho  quantity  of  pigment. 


25 

2.  The   Tessclated  Fundus    (Fig.   2). 

In  this  type  the  layer  of  pigiiicnt  epithelium  contains  less  coloring  mat- 
ter; consequently'  it  is  possible  to  see  througli  the  almost  transparent  retina 
and  to  perceive  the  markings  of  the  chorioid.  TJie  reddish  chorioidal  ves- 
sels are  seen  to  form  numerous  anastomoses,  and  the  pigment  of  the  chorioid 
is  massed  in  the  interv^ascular  spaces  between  them.  The  vessels  appear  as 
bright  bands  on  a  dark  background. 

3.  The  Albinotic  Fundus   (Fig.  3). 

In  this  t>'pe  the  layer  of  pigment  epithelium  contains  little  or  no  pigment, 
so  the  markings  of  the  chorioid  are  again  visible.  But  this  membrane  also 
has  no  pigment,  and  consequently  the  sclera  is  seen  to  shine  through  the 
retina  and  cliorioid.  forming  a  yellowish  white  background,  upon  which  the 
chorioidal  vessels  appear  as  dark  bands.  They  can  be  distinguished  from 
the  retinal  vessels  by  the  absence  of  the  light  reflex,  their  abundant  anas- 
tomoses, and  their  deeper  position. 

Cases  are  often  met  witli  which  do  not  belong  exclusivelv  to  any  one  type, 
but  present  the  characteristics  of  two  or  more.  The  laver  of  pigment  epithe- 
lium may  be  thick  enough  to  hide  the  markings  of  the  chorioid  in  some  places, 
while  in  others  it  is  thinner  and  allows  the  chorioidal  vessels  to  appear  on  a 
dark  (Type  II),  or  a  bright  background  (Type  III). 

The  pigmentation  is  usually  densest  about  the  papilla  and  in  the  region 
of  the  macula,  so  that  even  in  an  albinotic  fundus  the  chorioidal  vessels  are 
not  usually  visible  in  the  macula,  although  they  can  be  seen  in  the  less  pig- 
mented places   in  the  periphery. 

The  abundance  of  pigment  in  the  fundus  is  usually  in  keeping  with  that 
in  the  hair  and  skin  of  the  individual,  so  that  we  speak  of  a  blonde,  and  of  a 
brunette  fundus. 

The  retinal  vessels  can  easily  be  distinguished  from  the  chorioidal.  even 
in  the  albinotic  eye,  by  noting  the  following  characteristics : 

Retinal  Vessels  Chorioidal  Vessels 

appear  to  be  round,  appear  to  be  flat, 

have  light  streaks,  have  no  liglit  streaks, 

divide  dichotomously,  divide  irregidarly, 

form  no  anastomoses,  form  many  anastomoses, 

converge  toward  the  papilla,  have    no    uniform    direction,    or    con- 

verge  towai-d   tlie   periphery    (vor- 
tex veins), 
are   superficial.  are  deep. 

The  Course  of  the  Retinal  Vessels  varies  according  to  the  refraction 
of  the  eye.  In  myopia  they  are  markedly  drawn  out,  while  in  hypermetropia 
a  marked  tortuosity,  especially  of  the  veins,  can  often  be  seen.  This  tortu- 
osity is  due  to  the  growth   of  the  eyeball  being  too  little  as  compared  with 


!2() 

the  design  of  thu  vessels.  The  normal  conditions  of  circulation  (for  pressure 
pulse  see  page  107)  juid  tlic  absence  of  any  moriiid  symptoms  diflferentiate 
this  from  other  forms  of  tortuosity,  which  are  caused  by  morbid  conditions 
of  the  vessels  and   intlannnations. 

The  Retinal  Reflexes  form  a  very  marked  j)henomenon,  especially  in 
young  persons,  as  they  appear  chiefly  along  the  vessels  and  in  the  region  of 
the  macula  (see  Fig.  2).  They  appear  in  the  forms  of  bandlike,  or  island- 
like spots,  which  can  be  recognized  easily  to  be  reflexes  by  the  fact  that  tiiey 
change  their  forms  and  positions  with  movements  of  the  head  and  mirror. 
They  are  particularly  distinct  when  the  vision  is  focussed  on  the  deepest 
part  of  the  vitreous,  as  when  a  -f"l)  or  a  +-  ghiss  is  used  in  looking  at  the 
fundus  of  an  emmetropic  eye;  they  are  less  distinct  when  the  pupil  is  dilated 
than  when  it  is  contracted.  The  explanation  of  these  reflexes  is  that,  in  con- 
sequence of  the  elevation  of  the  surface  of  the  retina  by  the  vessels,  concave 
grooves  are  formed  which  act  like  concave  mirrors.  A  bright  curved  line  can 
be  seen  in  many  cases  on  the  nasal  side  of  the  papilla,  running  parallel  to  its 
margin  at  the  distance  of  about  one  papillary  diauRter.  This  is  known  as 
Weiss'  reflex  ring.  It  was  thought  by  its  discoverer  to  indicate  a  detach- 
ment of  the  vitreous,  and  to  be  pathognomonic  of  myopia,  but  this  theory 
cannot  be  correct,  as  the  line  is  met  with  in  ennneti'opia  and  hypermetropia. 
It  must  not  be  confounded  with  the  Weiss-Otto  shadow  ring,  which  is  met 
with  in  high  myopia  and  indicates  the  margin  of  a  sclerectasia,  the  so-called 
staphyloma  verum   (see  Fig.   73)- 

The  Chorioidal  Vessels  have  been  described  already,  so  it  will  suffice 
to  say  that  they  gather  the  blood  into  large  veins,  the  vortex  veins,  which, 
to  the  number  of  four  or  more,  usually  lie  in  the  periphery.  In  exceptional 
cases,  oftenest  in  myopia,  they  lie  at  the  posterior  pole,  as  shown  in  Fig.  3- 

Macula.  The  macula  deserves  a  special  description.  This  portion  of 
the  fundus  oculi  has  been  termed  the  macula  lutea  because  it  contains  a  yel- 
low coloring  matter;  yet  the  area  that  contains  this  yellow  coloring  matter 
is  considerably  larger  than  the  place  that  is  designated  ophthalmoscopically 
by  this  name.  It  mav'  be  recognized  from  the  behavior  of  the  blood  vessels, 
which  surround  and  direct  their  points  at  it  without  reaching  it.  The  area 
thus  surrounded  by,  but  lacking  in  blood  vessels,  lies  about  ll/o  papillary 
diameters  from  and  a  little  above  the  papilla.  It  has  the  form  of  an  oval, 
5  papillary  diameters  (P.  D.)  broad,  and  21/>  P.  D.  high.  Its  center  ap- 
pears rather  dark.  This,  the  macula  lutea  in  the  narrow  sense,  is  surrounded 
in  young  people  by  a  brilliant  reflex  ring  21/;  P.  D.  broad  and  1  P.  D.  high. 
This  ring  surrounds  the  part  of  the  macula  lutea  which  contains  no  nerve 
fibers.  In  the  center  of  this  ring  the  so-called  reflex  of  the  fovea  can  usually 
be  seen  in  children,  caused  by  the  reflection  of  the  light  from  the  sides  of  the 
foveal  funnel,  and  so  it  appears  sometimes  roiird,  sometimes  crescentic,  some- 
times wedgeshaped,  according  to  the  way  in  which  the  lifht  is  thrown  and  the 
mirror  held. 


PLATE  I 


Fig.  1.     Normal  Fundus  of  the  Uniform,  Stippled  Type 

Fig.  2.     Normal  Fundus  of  the  Tesselated  Type,  with  Numerous 
Reflexes  from  the  Retina 


Fig.  1.     Normal  Fundus  of  the  Uniform,  Stippled  Type 

(Sec  page  2-i) 

If  vrc  study  the  papilla  in  tlie  way  repeatedly  mentioned  in  the  text,  re- 
garding in  turn  its  form,  its  margins,  its  diirerenccs  of  level,  and  its  vessels, 
we  sec  the  folliiwiiig  details:  The  papilla  is  vertically  oval,  has  sharply  de- 
fined margins,  very  clearly  marked  connective  tissue  and  ])igment  rings,  and 
a  shallow  excavation  in  its  center.  It  is  normal  in  color,  the  temporal  por- 
tion distinctly  brighter  than  the  nasal.  The  j)igment  epithelium  is  so  dense 
that  no  details  of  the  chorioid  heneath  it  can  he  {)erceived.  The  pigment  is 
jiarticularly  concentrated  about  the  pa])illa  and  in  the  region  of  the  macula. 
The  dark,  larger  vessels,  without  distinct  light  streaks,  are  the  veins;  the 
brighter,  narrower  ones,  with  distinct  light  streaks,  are  the  arteries.  Al- 
though their  subdivision  is  not  quite  regular,  yet  the  division  above  and  below 
of  both  the  arteries  and  the  veins  into  2  principal  branches  can  be  seen. 
A  small  branch  of  the  artery  and  of  the  vein  approaches  the  macula. 


Fig.  2.     Normal  Fundus  of  the  Tesselated  Type,  with  Numerous 
Reflexes  from  the  Retina 

In  contrast  to  Fig.  1  the  markings  of  the  chorioid  can  be  seen  over  the 
greater  part  of  this  fundus.  This  is  because  the  pigment  layer  of  the  retina 
is  very  thin  and  allows  the  tissue  beneath  it  to  show  through.  The  dark, 
islandlikc  places  are  formed  by  the  pigment  of  the  chorioid  that  lies  between 
its  vessels  ( intervascular  spaces,  see  page  25).  As  the  vessels  of  the  chorioid 
are  brighter  than  the  pigment  lying  in  their  vicinity,  we  say  that  the  tes- 
selated fundus  is  characterized  b^'  bright  chorioidal  vessels  on  a  dark  back- 
ground. The  papilla  is  vertical^  oval,  and  has  a  distinct  connective  tissue 
ring,  but  no  pigment  ring.  Its  temporal  portion  is  brighter  than  its  nasal. 
The  pigment  of  both  the  retina  and  the  chorioid  is  lacking  in  its  vicinity, 
so  there  is  a  bright  zone  about  the  papilla.  The  macula  and  fovea  can  be 
seen  quite  distinctly  because  the  reflections  at  their  margins  and  along  the 
courses  of  the  vessels  are  verj"^  great.  The  bright  spots  in  the  vicinity  of  the 
macula  can  be  recognized  to  be  reflections  from  the  fact  that  they  change 
whenever  the  mirror  is  moved.  This  picture  shows  that  there  is  little  pig- 
ment in  the  retina,  but  plenty  in  the  chorioid. 


28 


Tab. 


Fig.  1. 


Fig.  2. 


PLATE  II 
Fig.  3.     Albinotic  Fundus 


Fig.  3.     Albinotic  Fundus 

This  picture  shows  a  complete  absence  of  pigment  in  both  the  retina 
and  chorioid.  The  vessels  of  the  latter  can  be  very  plainly  seen  to  unite  into 
larger  trunks,  the  vortex  veins.  The  arteries  and  veins  cannot  be  distin- 
guished from  each  other.  The  confluence  of  the  vessels  of  the  chorioid  in  the 
neighborhood  of  the  papilla  is  rather  unusual,  in  most  cases  this  takes  place 
in  the  periphery,  in  the  region  of  the  equator.  The  complete  absence  of 
pigment  in  the  region  of  the  macula  is  likewise  not  common ;  more  often  there 
is  a  distinct  accumulation  of  pigment  at  this  place,  even  when  the  albinism 
is  perfect  otherwise.  The  papilla  is  bright  red,  but  only  in  consequence  of 
the  effect  of  contrast  with  its  pale  surroundings,  its  margins  are  sharply  de- 
fined, the  excavation  is  vei-y  shallow,  the  retinal  vessels  are  normal. 

For  the  differentiation  between  the  vessels  of  the  retina  and  those  of  the 
chorioid,  see  page  2.5. 

A  partially  albinotic  fundus  is  shown  in  Fig.  8- 


30 


Tab.  a. 


Fig.  3. 


Conus  and  Staphyloma 

Differential  Diagnosis  of  the  White  Rings  and  Crescents  to  be 
Found  in  the  Immediate  Vicinity  of  the  Optic  Nerve 


Conus  and  Staphyloma 

Differential  Diagnosis  of  the  White  Rings  and  Crescents  to  be 
Found  in  the  Immediate  Vicinity  of  the  Optic  Nerve 

The  head  of  thi?  optic  norvc  affords  a  number  of  anoniiilics  of  tliis  nature 
which  are  apt  to  be  thought  parts  of  the  papilla  by  those  who  arc  not  expert, 
and  to  be  grouped  by  them  under  the  term  "large  papilla,"  but,  with  some 
attention  and  knowledge  to  the  factors  that  enter  into  the  problem,  it  is  not 
difficult  to  differentiate  the  individual  conditions,  and  to  draw  from  them 
important  conclusions  with  regard  to  the  diagnosis. 

The  principal  conditions  to  be  taken  into  account  are : 

1.  Conus  temporalis. 

2.  Staphyloma  posticum. 

3.  Peripapillary  atrophy  of  the  chorioid. 

4.  Conus  inferior. 

5.  Halo. 

6.  Medullated  nerve  fibers. 

I  exclude  here  all  inflammatory  affections,  such  as  optic  neuritis,  great 
fullness  of  the  vessels,  a?dema,  and  hemorrhage,  and  emphasi/.e  the  point  that 
this  classification  serves  a  purely  practical  purpose.  Conditions  are  grouped 
together  which  have  nothing  to  do  with  one  another,  either  anatomically  or 
etiologically,  but  have  only  some  features  in  common;  they  have  a  certain 
resemblance  to  one  another  in  form,  color,  and  ]>osition,  which  may  lead  those 
who  are  inexperienced  into  error,  and,  on  the  other  iiand,  one  of  them  may 
appear  alone  in  an  otherwise  normal  fundus.^ 

The  features  common  to  all  these  contlitions  are: 

1,  the  color,  which  is  usually  a  yellowish,  or  bluish  white; 

2,  the  position,  in  the  innnediate  neighborhood  of  the  ]>apilla  ; 

3,  the  form,  of  which  the  crescent  and  the  circle  are  the  principal  types ; 

4,  the  absence  of  signs  of  inflammation. 

In  order  to  differentiate  the  individual  conditions  we  will  group  tlirin  first 
with  regard  to  their  positions  as  respects  the  papilla,  as   they  are  seen  in 

'  A  number  of  other  conditions  mi.t;ht  be  inchnloJ,  sueh  as  cololioniii  of  the  sheath 
of  the  optic  nerve,  certain  forms  of  ooloboma  of  the  chorioid,  abnormal  developnient 
of  the  glia  tissue  and  of  connective  tissue,  but  they  have  been  omitted  because  of 
their  rarity. 

33 


34 

the  upright   imagu,   rt'inombering  that  everything  is  reversed  in  the  inverted 
image. 

(«)    On  its  temporal  side  lie,  or  may  lie 

tlie  conns  temporalis, 

the  st;ij)li\l()ma  posticnni, 

the  peripapillary  atroi)iiv. 

(b)  Belme  it 

the  conus  inferior, 
niedullatcd  ner\e  fibers. 

(c)  Surroitiiiliiig  it 

the  halo, 

the  staphyloma  posticum  annulare, 

the  peripapillary  atrophy. 

(f/)    Above  it 

medullatcd  nerve  fibers,  or 
the   peripapiUary    atrophy. 

Such  an  arrangement  as  this  may  seem  at  first  glance  to  be  rather  risky, 
because  other  conditions  may  combine  with  those  that  have  been  mentioned 
and  overthrow  the  artificial  fabric ;  thus  the  staphyloma  posticum  may  appear 
in  company  with  hemorrhages,  or  with  diseases  of  the  macula,  or,  in  excep- 
tional cases,  retinitis  albuminurica  may  present  an  appearance  which  seems 
at  first  sight  similar  to  that  of  these  conditions.  But  I  consider  this  differ- 
ential diagnosis  to  be  of  sufficient  importance  to  introduce  it  at  this  place 
in  spite  of  these  objections. 

1.  The  Conus  (Figs.  4  and  5)  is  a  uniformly  yellowish  white  crescent 
that  ordinarily  lies  to  the  temporal  side  of  the  nerve,  to  the  nasal  side  in  the 
inverted  image,  which  rarely  attains  at  its  widest  part  the  breadth  of  half 
the  diameter  of  the  papilla.  Toward  the  retina  it  usually  presents  a  more 
or  less  broad  edge  of  pigment.  Tiiis  is  the  connnon  form  of  conus,  which, 
when  typical,  can  be  distinguished  from  the  staphyloma  by  the  fact  that  it 
exhibits  no  visible  vessels  of  the  chorioid. 

The  conus  inferior  will  be  described  a  little  later. 

Certain  deviations  from  this  typical  form  are  met  with.  The  conus  may, 
though  rarely,  lie  on  the  opposite  side  of  the  nerve,  but  then  it  extends,  at 
least  partially,  toward  the  temporal  side.  In  rare  cases  it  may  surround 
the  papilla,  but  then  the  temporal  portion  is  the  broadest. 

The  color  may  vary  also.  The  crescent  may  be  white  only  at  the  mar- 
gin of  the  optic  nerve  and  may  have  a  reddish  yellow,  or  a  reddish  brown 
tone  toward  the  retina,  or  the  entire  crescent  may  be  of  such  a  color. 

A  change  in  the  medial  margin  of  the  sheath  of  the  optic  nerve,  the  so- 
called  supertraction,  may  be  found  comparatively  often  at  the  same  time 
with  the  conus  temporalis.  This  is  due  to  the  fact  that  the  retina,  chorioid, 
and  it  may  be  even  the  sclera,  cover  the  optic  nerve  at  this  place,  so  that  it 
can  be  seen  only  indistinctly  through  these  membranes. 


35 

The  conus  may  be  the  result  of  vai-ious  anatomical  conriitions,  which  dif- 
fer again  as  thev  are  congenital  or  accjuired. 

A.  The  congenital  conus  is  due  to  tlie  fact  that  the  outer  layers  of 
the  retina  and  of  the  pigment  epithelium,  as  well  as  the  chorioid,  are  rudi- 
mentary, or  not  formed  at  all,  over  the  area  that  is  white,  so  that  the  sclera 
shows  through.     This  form  differs  only  quantitatively  from  the  scleral  ring. 

It  can  readily  be  understood  that  this  form  of  conus  occurs  in  other 
than  myopic  eyes,  and  that  it  is  not  necessarily  strongly  marked  on  the 
temporal  side. 

B.  Acquired  conus.  This  is  the  result  of  the  stretching  that  takes 
place  in  the  posterior  part  of  the  globe  in  myopia.  It  may  be  caused  in  va- 
rious   ways,   and   it    is   necessary   to    recall    the   normal   configuration    of   the 


Pig.  I. — Head  of  the  Optic  Nerve  in  Myopia,  after  Fiichx. 

The  upper  drawing-  gives  the  ophthalmoseopie  appearance  presented  by  the  condition 
delineated  in  the  lower.     When  compared  with  Fig.  D  the  oblique  course  of  the 

optic  nerve  is  striking;  it  does  not  pass  through  the  sclera  thus  / \.  but 

thus  \ \.     Consequently  the  sclera  is  seen  through  the  retiua  and  chorioid 

on  the  temporal  side,  on  the  left  side  in  the  drawing,  which  gives  the  picture  of  a 
white  crescent,  or  conus.  On  the  opposite  side  the  optic  nerve  is  covered  by  the 
retina  and  chorioid,  partly  also  by  the  sclera,  so  that  this  portion  of  it  is  seen 
only  through  these  membranes  and  appears  as  an  indistinct,  ill-defined  crescent, 
which  is  called  the  supertraction  crescent. 


sclerotic  canal,  the  aperture  in  the  sclera  through  which  the  optic  nerve 
passes,  in  order  to  understand  it.  Normally  this  canal  forms  a  funnel  with 
its  smaller  opening  forward,  thus  /  ■  ■  ■  •\,  hut  when  a  conus  is  present  the 
temporal  side  has  been  ground  off  so  as  to  form  an  oblique  canal  vn\\\  parallel 


36 

walls,  tlius  \.  •  •  •\.  As  the  tissue  covering  the  optic  nerve  is  transparent 
the  wall  of  the  canal  at  this  place  can  be  seen,  and  forms  the  ophtiiahnoscopic 
picture  of  a  conus,  also  called  a  dint  ruction  cnscint. 

Another  form  of  conus,  calkd  the  retraction  crescent,^  is  produc(>d  in 
the  following  way : 

The  retina  antl  the  chorioid  do  not  yield  if|ualiy  in  the  stretching  at  the 
posterior  pole,  the  elastic  lamina  of  the  chorioid,  in  particular,  not  giving 
way  in  like  manner  as  the  retina.  As  it  does  not  simply  stop  at  the  margin 
of  the  optic  nerve,  but  is  intimately  united  with  its  interstitial  tissue,  a  fold 
of  the  optic  nerve  fil)ers  is  apt  to  be  torn  between  the  retina  and  the  stroma 
of  the  chorioid.  The  latter  then  perishes,  so  the  white  color  at  this  place 
is  caused  by  the  color  of  the  sclera  plus  that  of  the  glia  fibers  over  it. 

With  regard  to  the  origin  of  the  so-called  supertraction  crescent,  see. 
Fig.  I  in  the  text  and  the  accompanying  explanation. 

Aside  from  the  rare  cases  of  congenital  conus  that  may  be  met  with  in 
hypermetropia  and  enmietropia,  we  must  consider 

the  Conus  as  a  Sign  of  Myopia. 

We  may  go  even  a  step  farther.  There  are  two  forms  of  myopia,  the 
acquired  and  the  congenital.  'i"he  former  develops  during  school  life,  espe- 
cially in  children  in  the  higher  grades,  and  near  work  is  an  etiologic  factor 
in  its  production.  This  is  the  benign  form  of  myopia,  which  rarely  exceeds 
6  or  7  D,  and  is  complicated  only  in  exceptional  cases  by  diseases  of  the 
macula,  or  detachment  of  the  retina.  The  pathological  condition  in  this 
form  is  a  uniform  stretching  of  the  segment  of  the  eyeball  that  lies  behind 
the  equator.  As  this  process  of  stretching  is  very  slow,  uniform,  and  of 
comparatively  slight  degree,  and  as  it  usually  stojjs  when  the  body  ceases  to 
grow,  its  effect  is  exhausted  in  the  formation  of  the  conus  which  has  been 
mentioned. 

It  is  otherwise  with  congenital  -  myopia.  This  ordinarily  exhibits  patho- 
logically a  circumscribed  stretching,  confined  to  the  region  of  the  posterior 
pole,  but  one  which  is  much  more  marked  than  that  in  the  form  just  de- 
scribed. It  is  associated  with  a  greater  or  loss  degree  of  outward  bulging 
of  the  sclera,  and  gives  ophthalmoscopically  the  impression  of  a  staphyloma 
posticiun.      This  is   the  malignant    form,  which    is   apt  to  be   complicated  by 

^  The  nomenclature  of  these  crescents  is  not  uniform.  Many  writers  call  the  one 
here  named  the  retraction  crescent,  the  distraction  crescent,  and  vice  versa.  Others 
make  no  distinction  between  conus  and  staphyloma,  understanding  by  the  latter  only 
a  true  bulging  outward  of  the  posterior  pole  of  the  eyeball,  and  by  conus  the  ophthal- 
moscopic appearance  caused  by  that  condition,  indifferent  to  whether  it  presents 
obliterated  vessels  or  not. 

-  The  expression  "myopia  to  which  the  predisposition  is  congenital"  is,  perhaps, 
a  better  term  than  "congenital  myojiia."  for  one  that  develops  siwntaneously  without 
any  externa]  provocation,  like  near  work,  must  be  taken  into  account. 


37 


changes   in  the  macula   and   (litacliiiient  of  the  retina,  and   to  attain   a   high 


degree. 


Between  tliese  two  extremes  ari'  t i-ansitioiial  forms,  !)ut  in  general  it  may 
be  accepted  as  a  fact   tliat, 

the  conus  is  an  indication  of  acquired  myopia,  or  "school  my- 
opia," and  the  staphyloma  is  an  indication  of  congenital  myopia. 

2.  The  Staphyloma  (l""igs.  6,  70-73)  appears  ophthahnoscopically  as 
a  white  crescent,  usually  larger  than  a  conus,  which  is  situated  in  most  cases 
on  the  temporal  side  of  the  papilla.  Less  often  it  surrounds  the  nerve,  but 
even  then  its  broadest  part  is  on  the  temporal  side  of  the  latter.  In  contrast 
to  the  condition  presented  by  the  conus,  sclerosed  chorioidal  vessels  arc  found 
either  in  the  crescent,  or  in  its  immediate  vicinity. 

The  name  staplivloma  deserves  explanation.  Properly  speaking,  the 
above-mentioned  outward  bulging  of  the  posterior  pole  of  the  eye  is  to  he 
understood  when  we  speak  of  a  staplivloma,  but  the  term  is  also  applied  to 
the  crescent,  which  is  the  ophthalmoscojiically  visible  evidence  of  its  presence. 

Aside  from  an  outward  bulging  and  a  thinning  of  the  sclera,  the  same 
pathological  conditions  are  to  be  found  as  in  acquired  conus,  except  that 
atrophy  of  the  chorioid,  particularly  of  its  vessels,  forms  so  prominent  an 
addition  to  the  symptoms  that  wc  may  say,  cum  grano  salis: 

The  presence  of  sclerotic  r-es.icls  of  the  chorioid,  especiaU//  ii)  the  vicinity 
of  the  crescent,  is  indicative  of  staphi/lonui,  their  absence  of  conus. 

Still,  the  breadth  of  the  crescent  and  the  presence  of  other  changes  nmst 
be  taken  into  account  in  making  the  diagnosis. 

Fig.  6  shows  a  staphyloma  posticum  in  tlie  early  stage  of  its  develoj)- 
mcnt.  The  sharply  defined  crescent  can  be  seen  to  contain  chorioidal  vessels, 
some  of  which  are  totally  obliterated,  while  some  contain  blood,  with  the  black 
pigment  of  the  intervascular  spaces  distinctly  visible  between  them.  On  the 
farther  side  of  the  margin  of  the  staphyloma  are  to  be  seen  chorioidal  ves- 
sels that  have  undergone  similar  alterations,  but  these  are  still  covered  by 
the  veil  of  pigment,  which  is  absent  over  the  area  occupied  by  the  crescent. 
This  staphyloma  may  hasten  through  all  the  stages  of  atrophy  of  tlie  chorioid 
until  it  is  total,  as  shown  in  Fig.  54.  Sometimes  the  time  of  the  completitni 
of  the  atrophy  varies  in  different  parts  of  the  staphyloma,  so  that  breaks 
appear  through  which  the  pigment  of  the  chorioid  can  still  be  perceived  within 
it  in  some  places,  while  in  others  it  cannot  (Fig.  70).  In  many  cases,  how- 
ever, these  breaks  are  not  caused  by  the  unequal  advance  of  the  atrophy,  but 
by  shadows  that  are  produced  by  irregular  outward  bulgings  at  the  posterior 
pole.  Such  a  shadow  may  also  appear  around  the  posterior  pole,  but  it  is 
usually  to  be  seen  only  on  its  nasal  side,  and  is  frequently  double,  or  nndti- 
ple,  giving  rise  to  a  terraced  appearance  (Fig.  73).  A  fine,  brilliant,  re- 
flex curved  line  is  frequently  to  be  seen  on  the  nasal  side  of  the  ])apilla.  which 
was  once  thought  to  indicate  a  collection  of  fluid  between  the  retina  and  the 
chorioid,  and  a  commencing  detachment  of  the  vitreous,  but  this   interpreta- 


38 


Fig.  J. 

Schematic  sketch  to  show  how  the  papilhi 
is  caused  to  appear  out  of  drawinsr 
in  hifrh  myopia.  The  ectasia  affects 
exactly  the  posterior  pole  of  the  eye; 
the  papilla  is  situated  in  its  nasal 
■wall  and  is  consequently  seen  in  half 
profile  with  its  horizontal  axis  fore- 
shortened. The  white  crescent,  the 
staphyloma,  is  directed  toward  the 
center  of  the  ectasia. 


Fig.  K. 

In  this  case  the  ectasia  does  not  lie 
exactly  at  the  posterior  pole  but 
rather  below  it ;  hence  the  papilla  is 
not  situated  exactly  in  its  nasal  wall, 
but  in  its  upper  and  nasal,  and  the 
foreshortening  is  consequently  of  its 
oblique  axis.  The  white  crescent,  the 
staphyloma,  is  directed  toward  the 
center  of  the  ectasia. 


Fig.  L. 

In  this  case  the  ectasia  lies  to  the  nasal  side  of  the  posterior  pole  so  that  the  papilla 
occupies  the  bottom  of  its  cavity.  Consequently  we  look  directly  at  it,  and  it  ap- 
pears to  be  of  its  natural,  round  form.     The  staphyloma  is  circular. 


£9 

tion  is  not  correct,  as  sucli  a  lino  sometimes  appears  in  other  conditions  of  the 
refraction    (see  page  26). 

The  papilla  itself  may  appear  eitlii'r  normal,  or  reil(ii>h  and  indistinct 
when  a  staphyloma  is  present.  The  redness  and  indistinctness  are  due  partly 
to  the  pulling,  partly  to  the  effect  of  contrast  with  its  bright  surroundings. 
The  retinal  vessels  are  very  slender  and  drawn  out  (see  page  105).  The 
form  of  the  papilla  is  quite  interesting.  As  a  rule  it  is  not  round,  but  oval, 
with  its  short  diameter  vertical  to  the  broadest  part  of  the  staphyloma ;  i.e., 
if  the  latter  is  broadest  in  the  horizontal  meridian  the  papilla  appears  to  be 
vertically  oval ;  if  the  broadest  part  inclines  somewhat  downward  from  this 
meridian,  the  principal  axis  of  the  papilla  is  oblique.  The  explanation  of 
this  is  that  in  the  majority  of  cases  we  do  not  look  directly  at  the  papilla, 
in  consequence  of  the  ectasia  of  the  posterior  pole,  but  at  it  in  half  profile, 
as  has  been  shown  by  Dimmer.  The  papilla  lies  to  the  nasal  side  of  the  pos- 
terior pole  of  the  eye;  the  more  this  is  stretched  the  more  the  papilla  moves 
toward  the  inner  side  of  the  cavity  formed  by  the  ectasia ;  if  the  ectasia  is 
strictly  on  the  temporal  side  of  the  papilla,  the  latter  lies  strictly  on  the 
nasal  side  of  the  former,  and  the  foreshortening  then  affects  only  the  hori- 
zontal axis  (Fig.  J),  but  if  the  ectasia  is  downward  and  outward,  the  papilla 
clings  to  the  upper  inner  wall  of  its  cavity,  and  the  foreshortening  takes 
place  in  an  oblique  axis  (Fig.  K).  As  the  atrophy  of  the  chorioid  occurs 
chiefly  in  the  places  where  the  stretching  is  greatest,  this  relation  between 
the  form  of  the  staphyloma  and  that  of  the  papilla  is  readily  understood.  If 
the  ectasia  is  situated  on  the  nasal  side  of  the  posterior  pole  the  papilla 
occupies  the  floor  of  tiie  hollow  and  consequently  we  look  directly  at  it,  and 
as  the  hollow  made  by  the  ectasia  is  on  all  sides  of  the  papilla,  the  staphyloma 
is  circular  (see  Fig.  L). 

3.  Conus  inferior  (Fig.  8)- 

This  is  a  special  form  of  conus  which  is  to  be  regarded  as  a  rudimentary 
coloboma  of  the  chorioid.  Like  the  latter,  it  lies  l)elow  the  nerve,  and  is 
usually  associated  with  a  change  in  the  form  of  the  papilla,  which  is,  in  most 
cases,  obliquely  or  transversely  oval,  and  seems  to  be  smaller  than  normal. 
The  dividing  line  between  the  conus  inferior  and  the  papilla  frequently  is 
not  as  distinct  as  it  is  in  Fig.  8.  Anomalies  in  the  nature  of  the  excavation 
and  in  the  subdivision  of  the  vessels  are  often  present.  In  almost  all  cases, 
though  to  a  greater  degree  in  some  than  in  others,  the  color  of  the  fundus 
is  uniform  in  its  upper  part  and  almost  alhinotic  m  its  lower.  Astigmatism 
and  amblyopia  are  usually  associated  with  this  form  of  conus. 

The  conus  inferior  differs  plainly  from  the  staphyloma  posticum  and  the 
conus  myopicus  not  only  in  its  position,  but  also  in  the  absence  of  scleroses 
in  the  vessels  of  the  chorioid  and  in  the  form  of  the  papilla. 

4.  Peripapillary  Atrophy  of  the  Chorioid  (Fig.  65). 

Peri-   and  parapapillary   atrophy   of  the   chorioid,  the   result   of  arterio- 


40 

sclerosis,  is  quite  siiiiilur  in  appciirancc  to  staphylomn.  posticum.  It  is  char- 
acterized l)y  white  cords  formed  by  tiie  sck'rotic  vessels  of  the  chorioid,  while 
the  sharply  nut  lined  form  of  a  crescent  is  generally  absent.  Its  margins  arc 
indistinct,  and  it  sends  out  narrow  projections,  lii<e  feelers,  into  its  neiglibor- 
hood,  as  shown  in  Fig.  65-  It  is  onl}'  in  exceptional  cases  that  this  sclerosis 
takes  the  form  of  a  staphyloma  (Fig.  7)- 

5.  The  Halo  (Fig.  14). 

Tlie  halo  is  a  more  or  less  broad,  complete  or  partial,  yellowish-gray  cir- 
cle which  is  inmiediately  adjacent  to  the  ])apilla,  and  fades  away  into  its 
surroundings  witli  an  indistinct  margin.  It  is  met  witli  in  old  people,  the 
halo  senilis,  and  in  glaucoma,  the  halo  glaucomatosus.  The  halo  corre- 
sponds to  an  atrophy  of  the  chorioid  and  of  the  pigment  epithelium,  yet  no 
sclerotic  vessels  can  usually  be  seen  within  it  ophthalmoscopically.  Some- 
times the  ring  has  a  more  yellowish,  or  reddish  tinge  of  color,  which  may  be 
caused  by  the  simultaneous  presence  of  an  exutlate  between  the  chorioid  and 
the   retina. 

The  halo  glaucomatosus  can  readily  be  diagnosed  as  such  when  the 
course  of  the  retinal  vessels  is  noticed.  A  single  vessel  that  bends  sharply 
over  the  margin  of  the  pajjilla  suffices  to  make  the  diagnosis  of  glaucoma 
positive  and  to  reveal  the  true  nature  of  the  ring.  On  the  other  hand,  the 
halo  senilis  can  l)e  readily  distinguisjicd  from  staphyloma  by  the  absence  of 
visible  vessels  of  the  chorioid,  from  the  scleral  ring  by  the  indistinctness  of 
its  margins,  and  from  the  tissue  of  the  pa})illa  by  its  color. 

6.  MeduUated  Nerve  Fibers  (Fig.  9). 

The  fibers  of  the  optic  nerve  are  accustomed  to  lose  their  medullary 
sheaths  before  they  pass  through  the  lamina  cribrosa  and  consequent!}'  be- 
come transparent,  but  in  exceptional  cases  the  fibers  retain  their  slieaths  as 
they  spread  out  in  the  retina  and  hide  all  the  tissues  beneath  them  with  a 
mantle  that  is  sometimes  yellowish  white,  sometimes  bluish  white. 

The  color  varies  according  to  the  density  and  number  of  the  fibers.  It 
is  a  ])ure  white  when  the  fibers  of  the  entire  layer  are  opaque;  it  is  a  reddish 
yellow  when  the  density  of  the  fibers  is  slight,  in  consequence  of  the  color  of 
the  subjacent  portion  of  the  fundus. 

It  hap])ens  very  rarely  that  the  medullary  sheaths  of  the  orbital  segment 
of  the  optic  nerve  continue  without  interi-u])tion  into  the  intraocular  portion; 
in  most  of  these  cases  the  sheaths  tliscontinue  at  the  lamina  cribrosa  and 
reappear  a  little  farther  on,  as  the  fibers  spread  out  in  the  papilla  or  the 
retina. 

These  fibers  usually  adhere  to  the  papilla  and  lie  above  or  below  it  for  the 
most  part,  very  often  covering  the  corresponding  margins.  The  uncovered 
portion  of  the  papilla  then  appears  particularly  dark  red  from  the  effect  of 
contrast.  These  fibers  never  have  a  sharp  margin,  but  send  flamelike  pro- 
cesses into  the  normal  retina.     Usually  a  distinct,  radiating  striation  can  be 


41 

perceived  in  the  white  area.  The  deep  vessels  of  the  retina  may  be  com- 
pletely covered  by  these  nieduUated  nerve  fibers,  while  the  superficial  ones 
may  jut  out  more  or  less  sliarply  from  the  wliite  mass  (see  page  102). 

This  behavior  of  the  vessels  of  the  retina,  the  indistinct  border,  the  color 
and  the  striation  are  sufficient  to  differentiate  medullatcd  nerve  fibers  from 
conus,  staphyloma,  and  peripapillary  atrophy;  the  absence  of  all  other  patho- 
logical changes,  such  as  hemorrhage  and  oedema,  as  well  as  its  innnediate  con- 
nection with  the  papilla,  serve  to  distinguish  them  from  exudates  and  from 
patches  of  degeneration  (see  page  128). 

Rabbits  (Fig.  86)  always  have  medullatcd  nerve  fibers  in  their  retinae, 
horses  have  them  very  often. 


PLATE  III 

Fig.  4.     Conus  Temporalis 
Fig.   5.     Conus  Temporalis,   Supertraction   in  "School"   Myopia 


Fig.  4.     Conus  Temporalis 

(See  page  33) 

Next  tlie  temporal  margin  of  the  disc  of  tlie  optic  nerve  is  a  narrow  white 
crescent  wiiicii  is  separated  from  the  rest  of  the  fuiuhis  hy  a  sharply  defined 
edge.  The  papilla  plus  the  crescent  is  surrounded  by  a  strongly  pigmented 
ring.  For  the  anatomical  explanation  of  such  a  crescent,  see  page  34.  An 
artery  arises  from  tlie  line  of  delimitation  between  the  papilla  and  the  conus, 
wliich  does  not  come  from  the  central  artery  of  the  retina,  but  from  Zinti's 
arterial  plexus,  and  is  a  cilioretinal  artery  (see  page  23). 

The  head  of  the  optic  nerve  shows  a  distinct  excavation  in  its  temporal 
portion. 

Fig.   5.     Conus  Temporalis,   Supertraction   in   "School"   Myopia 

(See  page  34) 

At  the  temporal  margin  of  the  head  of  the  optic  nerve  is  a  crescent  some- 
what different  in  form  and  color  from  that  shown  in  Fig.  4.  The  excavation 
is  very  deep  and  the  meshes  of  the  lamina  cribrosa  are  to  be  seen  distinctly 
in  its  floor.  The  sclera  is  drawn  over  the  nasal  margin  of  the  papilla,  in 
consequence  of  which  its  outline  is  indistinct  (see  page  34).  The  fundus 
is  uniformly  pigmented,  on  the  whole,  hut  at  certain  places  the  vessels  of  the 
chorioid  may  be  seen  through  the  pigment  layer. 


44 


Tab.  3. 


Fig.  4. 


Fig.  5. 


PLATE  IV 

Fig.  6.     Commencing  Staphyloma  Posticum  in  "Congenital" 

Myopia 

Fig.  7.     Crescentic  Sclerosis  of  the  Chorioid  Due  to 
Arteriosclerosis 


Fig.  6.     Commencing  Staphyloma  Posticum  in  "Congenital" 

Myopia 

(St'c  page  iJT) 

The  term  staphj'loma  posticum  is  made  to  include  not  only  tlie  outward 
bulging  of  the  eyeball  at  its  posterior  pole,  but  also  the  change  in  the 
chorioid  induced  by  it  close  to  the  head  of  the  optic  nerve.  The  epithelium 
of  the  retina,  which  is  not  very  thick  elsewhere  in  the  fundus  (tesselated  fun- 
dus, see  Fig.  2),  has  undergone  total  atrophy  over  the  area  of  a  parapapil- 
lary  crescent,  and  so  allows  the  markings  of  the  chorioid  to  be  seen  distinctly. 
The  visible  vessels  of  the  chorioid  are  almost  wholly  obliterated,  so  that  the 
chorioidal  pigment  wliich  lies  between  them  conies  out  very  plainly.  If  this 
pigment  also  should  disappear  in  the  course  of  the  disease  the  crescent  would 
become  pure  white  and  resemble  the  conus  in  Fig.  4  (compare  \vith  the  sche- 
matic drawing  in  Fig.  54).  The  neighboring  vessels  of  the  chorioid  appear 
to  be  diseased,  an  indication  tiiat  "congenital"  myopia  has  a  progressive 
character.  This  picture  was  taken  from  the  eye  of  a  I)oy  10  years  old,  who 
had  12  D  of  myopia  (see  page  37). 

The  papilla  itself  and  the  retinal  vessels  are  normal. 


Fig.  7.     Crescentic  Sclerosis  of  the  Chorioid  Due  to 
Arteriosclerosis 

(See  page  39) 

A  picture  can  be  produced  by  arteriosclerosis  that  closely  resembles  the 
preceding.  The  presence  of  pigment  between  the  sclerotic  vessels  of  the 
chorioid  is  only  suggested.  This  picture  was  taken  from  the  eye  of  a  man 
68  years  old,  whose  refraction  was  emmetropic.  As  the  sclerosis  of  tlie 
vessels  advances  such  pictures  may  be  created  as  those  shown  in  Fig.  65. 


46 


Tab.  4. 


Fig.  6. 


Fig.  7. 


PLATE  V 

Fig.  8.     Conus  Inferior;  Partial  Albinism 
Fig.  9.     Medullated  Nerve  Fibers 


Fig.  8.     Conus  Inferior;  Partial  Albinism 

(See  page  39) 

The  papilla  has  a  reinarkahlj  transversely  oval  form  which  is  completed 
into  ;i  circle  by  the  adjacent,  or  rather  subjacent,  crescent. 

The  line  of  demarcation  between  the  pajjilla  and  the  conus  is  not  always 
as  sharply  defined  as  it  is  in  this  case.  Dark  spots  can  l)e  seen  scattered 
about  in  the  conus   (see  pa^e  .'39). 

The  jxirtion  of  the  fundus  in  tiie  vicinity  of  the  conus  is  distinctly 
albinotic,  while  the  rest  of  it  is  unifoi-mlv  colored. 


Fig.  9.     Medullated  Nerve  Fibers 

(Sec  pages  -K)  and   128) 

Medullated  nerve  fibers  ordinarily  lie,  as  in  this  case,  in  immediate  con- 
nection with  the  papilla  and  extend  out  from  it.  The  papilla  seems  to  be 
redder  than  usual  from  the  effect  of  contrast.  The  fibers  conceal  what- 
ever lies  beneath  them,  e.g.,  the  more  intense  color  of  the  pigment  epithelium 
generally  to  be  found  in  the  vicinity  of  the  papilla.  As  they  overlie  in 
part  the  vessels  of  the  retina  the  latter  appear  to  be  narrowed  in  certain 
places.  They  form  a  mass  that  is  striated,  is  brilliant  white,  and  that 
often  ends  in  delicate,  separate  fibers  which  look  like  white  hairs.  In  rare 
cases  these  patches  may  be  of  considerable  extent,  but,  almost  invariably 
they  follow  the  courses  of  the  vessels  of  the  retina.  Although  they  are 
usually  in  immediate  connection  with  the  papilla,  they  may  be  found  separate 
from  it  in  exceptional  cases.  For  the  cJiffcrential  diagnosis  from  other  con- 
ditions, particularly  from  albuminuric  retinitis,  see  page  128.  These  fibers 
form  an  absolutely  harmless  congenital  'inomaly.  The  rest  of  the  fundus 
is  normal. 


•18 


Tab.  5. 


Fig.  8. 


Fig.  ')■ 


Atrophy 
Atrophy  of  the  Optic  Nerve 


ATROPHY 

The  changes  in  tlie  optic  nerve  are  to  he  considered  mainly  from  4  points 
of  view    for  the  purpose  of  diagnosis: 

1.  Color  and  Transparency. 

2.  Margins. 

3.  Conditions  of  Level. 

■i-  Conditions  of  the  Vessels. 

The  alterations  in  color  ami  in  the  margins  are  apt  to  be  the  most 
significant,  so  the  changes  in  the  optic  nerve  will  be  grouped  first  from 
these  points  of  view. 

Whiteness  of  the  Optic  Nerve. 

It  must  be  understood  from  the  start  that  tlie  ophthalmoscopic  condi- 
tion alone  does  not  suffice  to  establish  the  diagnosis  in  many  cases,  but 
that  tiie  simultaneous  determination  of  the  vision  and  of  the  visual  field  is 
imperatively  demanded. 

The  use  of  indirect  illumination  is  often  of  value  in  cases  of  commencing 
atrophy.  For  this  purpose  the  mirror  is  turned  a  little  to  one  side,  while 
the  observer  is  looking  at  the  papilla,  so  that  the  apex  of  the  cone  of  light 
falls  onh'  on  the  margin  of  the  papilla.  Slight  changes  in  the  color  of  the 
latter  then  become  plainly  visible. 

A  guide  to  the  differential  diagnosis  of  the  various  forms  of  atrophy 
can  be  found  on  the  next  page.  It  may,  perhaps,  appear  too  schematic  to 
many;  I  readily  admit  that  in  individual  cases  the  differential  diagnosis,  for 
example,  between  nutritional  and  simple  atrophy,  is  by  no  means  as  easy  as 
might  be  supposed  from  the  chart,  but  yet  the  medium  types  can  be  distin- 
guished by  it,  and  this  forms  its  justification. 

Some  remarks  concerning  the  so-called  atrophic  excavation  niay  be 
in  order  before  passing  to  the  consideration  of  the  individual  forms  of 
atrophy. 

Following  the  lead  of  t'.  Jaeger,  many  autliors  speak  of  an  atrophic 
excavation,  yet  Elschnig  is  right  when  he  maintains  that  no  such  picture  can 
be  seen  either  with  the  ophthalmoscope  or  with  the  microscope,  and  tiiat  its 
occurrence  cannot  be  understood  pathologically,  because  the  nerve  fibers 
alone  disappear  in  atrophy,  leaving  the  stroma  and  connective  tissue,  the 
latter  of  which  is  sometimes  increased.    When  a  large  physiological  excavation 

51 


52 


DIFFERENTIAL   DIAGNOSIS   OF  THE   VARIOUS   FORMS   OF 

ATROPHY 


Color 

Margin 

Conditions  of 
Level 

Vessels 

Visual  Field 

Tabetic 

atrophy 

1" 

2 
1 

gray  white 
white 

distinct 

normal 

normal 

loss  of  sectors, 
concentric 
contraction 

Atrophy 
from  inter- 
ruption of 
conduction    j 

white 

distinct 

normal 

normal 

usually  amau- 
rosis is  present 

Nutritional   atro- 
phy (atrophy  after 
occlusion  of 
arteries ) 

white 

distinct 

normal 

arteries  small, 

threadlike 
when  occluded 

variable 
(amaurosis  af- 
ter occlusions) 

Glaucomatous                       ... 
atrophy              '  ^'""y  "''^■''^ 

distinct, 
sometimes 
with  a  halo 

deep,  abrupt 

excavation  to 

the  margins  of 

the  nerve 

vessels  bent  like 
hooks  at  the 
margin  of  the 
papilla ;  veins 
eiifTorfred  and 
tortuous;  arte- 
rial pulse 

nasal  contrac'- 
tion ;  more  rare- 
ly concentric 
contraction 

Neuritic  atroi>hy 
(atrophy  after 
choked  disk) 

white 

indistinct 

normal ;  after 

choked  disk 

rather  elevated 

papilla 

veins  engorged, 

tortuous,  and 

sheathed 

variable 

Ketinitic  atrophy 

pale  yellow, 

or  dirty 

reddish  to 

gray  yellow 

obscured 

normal 

threadlike 

very  great 
concentric 
contraction 

Atrophy  of  the      ^^^^:'f,. 
papiUomacular           .V,        ."r 

bundle  from  toxic  '"^|:' ;;;^'*'' 

causes  and  mul-           ,  ..'^  ',?, 
tiple  sclerosis         ^^^^^ 

distinct 

normal 

normal 

central  scotoma 

for  green  and 

red,  later  for 

all  colors 

already  exists  it  may  .seem  to  become  enlarf^ed  by  the  rounding  off  of  its 
margins,  especially  when  tlie  difference  of  color  between  the  papilla  and  the 
ffoor  of  the  excavation  disappears  as  the  atrophy  progresses;  but  even  in 
such  a  case  it  is  better  to  speak  of  an  atrophy  with  a  large  physiological 
excavation,  than  of  an  atrophic  excavation. 

We  have  to  distinguish  between  total  and  partial  atrophies.  This  can 
apply  naturally  only  to  the  completed  condition  characteristic  of  the  clinical 
picture,  for  in  commencing  total  atrophy  the  process  will  be  most  marked 
at  the  place  where  the  nerve  fibers  ai-e  weakest,  where  a  brighter  tone  of  color 
prevails,  i.e.,  on  the  temporal  side  of  the  papilla,  so  that  in  this  stage  the 
total  may  present  the  appearance  of  the  partial  atrophy.  On  the  other 
hand,  a  partial  atrophy  that  has  existed  for  years  may  become  total. 

It  follows  from  what  has  been  said,  and  from  xchat  is  yet  to  come,  that  we 
must  nt)t  be  contented  with  the  diagnosis  "atrophi/,"  hut  must  trif  to  ascer- 
tain the  specific  diagnosis  of  simple,  neuritic,  and  other  forms,  from  the  sijmp- 


53 

toms  that  are  present.  This  uill  not  prove  difficult  to  those  zc-ho  ore  accus- 
tomed to  consider  the  papilla  always  from  the  ^  points  of  view,  to  take  into 
account  its  color,  miiryins,  level,  and  vessels. 

A.   Total  Atrophy 

1.  Simple  Atrophy^    (Figs.   10  and   11). 

Simple  atrophy  presents  the  foHowing  characteristics: 

Color:  white  to  gray  white. 

Margins :  -  normal. 

Level:  normal. 

Vessels :  normal. 

Hence,  the  color  alone  is  changed. 

The  retinal  vessels  may  become  smaller  in  the  later  stages,  so  as  to  resemble 
nutritional  atrophy,  but  this  does  not  belong  to  the  typical  picture. 

What  etiological  conclusions  can  be  drawn  from  such  a  condition?  Un- 
fortunately, very  many.  The  atrophy  may  be  of  a  true  neurogenous  origin, 
caused  by  cerebral  disease,  when  it  is  primary,  or  it  may  be  due  to  injuries 
or  compressions,  when  it  is  secondary.  We  see  the  same  picture  in  both 
cases.  The  true  diagnosis  will  depend  therefore  on  the  findings  in  the  general 
and  neurological  examination,  unless  we  are  able  to  find  other  points  in  the 
eye  that  are  of  diagnostic  assistance.  Primary  atrophy  is  the  same  as  that 
which  has  frequently  been  termed  gray  atrophy,  but — we  may  almost  say 
again  unfortunately — the  color  has  no  signification  in  the  differential  diag- 
nosis. In  the  first  place,  the  gray  tone  of  color  is  met  with  comparatively 
seldom ;  in  the  second,  it  has  been  seen  many  times  in  other  forms ;  in  the 
third,  it  may  disappear  and  give  place  to  a  white  tone  after  it  has  once 
been  observed,  or  the  reverse  may  take  place.  As  the  other  ophthalmoscopic 
details,  the  margins,  level  and  vessels  show  no  deviation  from  the  normal  in 
typical  cases,  we  have  to  include  under  the  caption  of  simple  atrophy  clinical 
pictures  which  are  etiologically  very  different.  This  is  why  it  is  so  important 
to  notice  all  other  ocular  symptoms,  and  to  investigate  the  general  condition. 

Etiologically,  tabes  is  the  first  disease  to  be  thought  of;  then  come 
general  paralysis  and  syphilis.  Syphilis  of  the  optic  nerve  usually  appears 
in  the  form  of  a  neuritis,  or  of  a  neuritic  atrophy,  yet  syphilitic  diseases 
of  parts  that  are  situated  more  centrally,  such  as  meningitis,  gumma  of  the 
chiasm,  and  hydrocephalus,  may  cause  a  simple  atrophy  secondarily.  Tabes 
surpasses  everything  else  in  importance.  Tabetic  atrophy  begins,  as  a  rule, 
very  early  in  the  disease  and  may  be  for  years  its  only  symptom.     It  rarely 

1  A  number  of  animals  have  perfectly  white  papillse.  for  example,  the  rhinoceros, 
the  armadillo,  the  porcupine,  the  anteater,  and  the  hedsrehog-. 

2  When  a  eonus  or  a  staphyloma  is  annexed  to  the  atrophic  papilla  it  may  be 
differentiated  from  the  latter  by  the  fact  that  it  presents  a  peculiar,  ruther  yellowish 
white,  instead  of  the  white  of  the  papilla. 


54 

appears  at  the  same  time  with  the  ataxia  of  tlie  lower  liiiihs.  Out  of  the 
large  number  of  patients  tliat  I  Iiave  seen  who  were  hhiulcd  by  this  disease, 
I  can  reeollect  only  a  very  few  who  had  a  high  degree  of  ataxia.  Althoiigii 
it  is  to  be  feared  that  a  tabetic  who  closes  his  eyes  will  lose  his  balance  and 
fall,  because  of  his  ataxia,  these  blind  persons,  in  whom  likewise  the  sense 
of  sight  for  orientation  is  absent,  go  about  quite  well,  antl  present  the  same 
appearance  as  other  blind  persons.  Tabetic  atroj)hy  almost  always  affects 
both  eyes  and  leads  to  blindness,  though  with  remissions. 

Tabes  frequently  causes  an  ocular  triad;  atrophi/  of  the  optic  nerve,  paresis 
of  the  ocular  muscles,  reflex  imvtohflit//  of  the  pupils. 

Differential  diagnosis.  When  we  find  a  reflex  immobility  of  the  pupil 
associated  with  a  simple  atrophy  of  the  optic  nerve,  the  case  is  one  of  tabes; 
when  the  immobility  of  the  pupil  is  absolute,  i.e.,  when  the  pupil  does  not 
react  to  either  light  or  convergence,  especially  when  the  pupil  is  also  dilated, 
general  paralysis  or  syphilis  is  probably  present.  Meiosis  occurs  only  in 
tabes.  On  the  other  hand,  the  reactions  of  the  pupil  may  be  preserved  in 
syphilis,  while  this  is  almost  never  the  case  in  tabes.  A  paresis  of  the 
abducens,  or  a  paresis  of  a  portion  of  the  oculomotorius,  is  indicative  of 
tabes,  while  a  facial  paresis,  especially  in  connection  with  symptoms  of  hemi- 
plegia, points  rather  toward  general  paralysis. 

Sometimes  syphilis  appears  quite  like  tabes  in  its  accompanying  symp- 
toms, and  then  the  differential  diagnosis  may  be  very  difficult,  the  more  so 
as  Wassermann\'i  reaction  is  often  positive  in  tabes.  Atrophy  of  only  one 
optic  nerve,  an  accompanying  hemianopsia,  total  internal  ophthalmoplegia, 
bilateral  paresis  of  the  oculomotor  nerve,  or  bilateral  ptosis,  generallv  indi- 
cate that  the  disease  is  syphilitic  rather  than  tabetic. 

The  field  of  vision  in  tabes  usually  shows  sectorlike,  or  concentric  losses. 
A  central  scotoma  with  total  atrophy  is  indicative  of  syphilis,  with  partial 
atrojihy  of  nniltiple  sclerosis.^ 

None  of  the  other  causes  are  very  frequent.  Among  them  may  be  men- 
tioned as  particularly  important,  interruption  of  the  conductivity  of  the 
optic  nerve  (Fig.  10)  by  direct  or  indirect  injuries,  as  in  fracture  of  the 
base  of  the  skull,  compression  in  the  optic  canal,  as  in  oxyccphalus,  slowlv 
growing  tumors  at  the  base  of  the  skull,  hydrops  of  the  third  ventricle,  and 
pressure  of  the  arteriosclerotic  carotid  upon  the  intracranial  portion  of  the 
nerve. 

Pathologically,  simple  atrophy  of  the  fibers  of  the  optic  nerve  takes 
place   without    material   proliferation    of   connective    tissue;   both   the   vessels 

^  In  the  rare  cases  of  tabes  with  central  scotoma  there  is  a  concentric  contraction 
at  the  same  time;  this  is  not  present  in  multiple  sclerosis.  Another  dilTereuce  be- 
tween tabes  with  central  scotoma  and  multiple  sclerosis  is  that  in  the  former  the 
papillae  are  pale  at  a  time  when  the  vision  is  still  good,  while  in  multiple  sclerosis  it 
is  the  vision  that  is  lost  first,  it  may  be  rather  suddenly,  and  the  papilla  subsequently 
becomes  pale. 


55 

and  the  capillaries  are  preserved.  Hence  the  white  or  gray  discoloration 
of  the  papilla  cannot  be  caused  in  tiiis  way.  It  is  probably  due  to  the 
changed  optical  conditions  induced  by  tiie  atrophy  of  the  nerve  fibers,  whicli 
make  it  possible  for  the  lamina  cribrosa  to  reflect  the  liglit  that  falls  upon 
it  more  sharply  and  in  greater  quantity  than  it  can  under  normal  conditions. 

2.  Nutritional  Atrophy. 

The  appearance  of  this  may  be  extremely  like  that  of  the  atrophy  just 
described.  Only  the  absolutely  negative  evidence  of  a  neurological  and  internal 
examination,  with  the  exception  of  an  arteriosclerosis  that  is  often  moderate, 
together  with  the  condition  of  the  retinal  vessels,  proves  the  diagnosis.  As 
is  to  be  expected  in  arteriosclerosis,  this  form  of  atrophy  is  usually  met 
with  in  old  people.  It  is  not  rarely  found  in  company  with  arteriosclerotic 
vessels  in  the  chorioid,  which  often  surround  it  like  a  staphyloma  (see  page 
39).  For  this  reason  the  margins  of  the  papilla  appear  somewhat  indis- 
tinct in  many  cases,  but  this  is  due  only  to  the  absence  of  contrast.  Other- 
wise the  margins  in  this  form  are  sharply  defined,  the  level  is  normal,  tiie 
vessels  alone  are  altered.  In  many  of  these  cases  the  first  things  that  can 
be  seen  by  accurate  observation  are  irregularities  of  caliber,  thickenings  of 
the  walls,  and  obliterations  of  the  smaller  vessels,  such  as  will  be  described 
later  under  "The  Changes  in  the  Vessels  of  the  Retina,"  and  are  considered 
to  be  characteristic  of  arteriosclerosis  of  these  vessels.  The  visual  disturb- 
ances are  comparatively  trivial  in  these  cases,  and  the  atrophy  caused  by 
chronic  disturbances  of  nutrition  are  differentiated  by  this  fact  from  the 

Atrophy  Due  to  Occlusion  of  the  Arteries 

The  picture  of  acute  occlusion  of  an  artery  is  shown  in  Figs.  44  and 
45,  and  is  described  on  page  150.  After  the  acute  symptoms  have  passed 
away  a  condition  develops  which   is  illustrated  by  Fig.   16. 

The  arteries  are  threadlike,  no  longer  visible  in  some  places,  the  optic 
disk  is  white,  with  normal  margins  and  level ;  usually,  though  not  always, 
small  patches  of  degeneration  are  found  in  the  macula,  which  are  called 
coronuhe  and  are  described  on  page  127. 

The  vision  is  usually  totall}-  lost  in  these  cases. 

3.  Glaucomatous  Atrophy  (Fig.   14). 

The  color  in  this  form  of  atrophy  is  a  gray  white  rather  than  a  pure 
white,  as  a  rule;  tlie  margins  of  the  papilla  are  sharply  defined,  but  in  many 
cases  they  seem  to  be  obscured  by  a  surrounding  ring,  tlie  so-called  halo. 
We  should  observe  carefully  where  the  papilla  stops  and  the  halo  begins, 
the  line  of  separation  can  usually  be  recognized  plainly  from  the  differ- 
ence in  color  between  the  two.  The  vessels  are  rarely  quite  normal,  the 
veins  are  usually  In'oad.  sometimes  varicose,  while  the  arteries  are  engorged 
only  at  first,  frequently  pulsate,  but  later  appear  to  be  contracted. 


56 

This  form  is  sli;ir])l_v  (lillVrinl  iaicil  from  all  otliers  by  the  behavior  of 
the  vessels  at  the  mart^iii  of  thr  jiapill.i.  As  can  be  phiiiily  seen  in  Fig.  14, 
tlic    course    of    the    vi'ssels    up    to    the    marniii    of    tlie    optic    disk    is    perfectly 


^ 


J 


.J 


Fin.  M. — (ilaueomatiuis  Exeuvation. 

The  exeavation  be.ains  sharply  at  tlie  margin  of  the  papilhi.  The  optic  nerve  is 
laterall.v  ponched  out  on  its  nasal  side.  When  we  look  from  in  front  upon  a  ves- 
sel that  dips  down  at  this  place  it  will  not  be  visible  as  it  courses  along  this 
pouch,  but  will  apparently  come  to  an  end  at  the  margin  of  the  papilla.  The 
optic  nei"ve  itself  is  reduced  by  atroph.v.  These  pathological  conditions  correspond 
to  what  is  seen  ophthalmoscopically  in  Fig.   14. 


Fig.  N. — Deep  Physiological  Excavation. 

In  contrast  to  the  preceding  drawing  the  excavation  does  not  begin  at  the  margin  of 
the  papilla,  but  normal  tissue  lies  between  the  margins  of  the  disk  and  of  the 
excavation.  A  vessel  coursing  over  the  margin  of  the  excavation  may  bend  in  a 
manner  similar  to  that  followed  by  those  in  a  glaucomatous  excavation,  but  this 
bend  does  not  take  place  at  the  margin  of  the  papilla.  The  corresponding  oishthal- 
moscopic  picture  is  Fig.  15. 


57 

normal,  but  tlifre  thuy  Ix'nd  suddenlj-  and  sucni  to  disappear  in  tlic  cavity; 
it  is  only  by  a  change  of  focus — in  the  direct  method  by  the  interposition 
of  a  concave  glass — that  they  can  be  seen  in  the  floor  of  the  excavation. 
From  the  difference  in  focus  and  from  the  parallactic  displacement  (see 
page  9)  between  the  vessels  on  the  margin  of  the  pajjilla  and  those  on  its 
floor,  the  difference  of  level  between  the  excavated  papilla  and  its  surrnumi- 
ings  can  be  determined.  The  floor  of  the  ])apilla  usually  lies  1  mm  behind 
the  level  of  the  retina.  The  fact  that  it  is  abrupt  and  extends  to  the  margin 
distinguishes  the  glaucomatous  from  the  physiological  excavation.  When- 
ever a  vessel  is  seen  to  make  a  distinct  hook  over  the  margin  of  the  papilla 
the  diagnosis  of  glaucoma  is  justified.  Usually  the  excavation  is  total.  The 
markings  of  the  lamina  cribrosa  are  very  plainly  visible  in  fresh  cases,  but 
in  older  ones  they  are  hidden  by  the  proliferation  of  connective  tissue.  It  may 
be  said  here  that  the  color  of  the  optic  nerve  need  not  be  abnormal  in  the 
commencement  of  a  glaucoma,  but  that  the  excavation  and  the  behavior 
of  the  vessels  suffice  for  the  diagnosis.  Moreover,  under  the  influence  of  an 
antiglaucomatous  treatment  the  excavation  undergoes  involution  in  many 
cases. 

In  old  glaucomatous  eyes  we  find  obliterations  of  the  vessels  throughout 
entire  areas  of  the  retina,  as  well  as  a  new  formation  of  large  vessels  at  the 
margin  of  the  papilla,  or  in  the  excavation;  sometimes  junctions  between  the 
retinal  and  chorioidal  vessels,  the  so-called  opticociliary  vessels,  are  also  to 
be  seen  (see  page  10-i). 

4.  Ncuritic  Atrophy  (Figs.   12  and  13). 

Neuritic  atrophy  is  clearly  distinguishable  from  all  of  the  other  forms 
by  the  indistinctness  of  the  margins  of  the  papilla,  and  by  the  invisibility 
of  the  apertures  in  the  lamina  cribrosa. 

In  the  atrophy  that  follows  neuritis,  or  choked  disk,  the  papilla  is  at  first 
white  gray  with  striated  or  obscure  margins,  but  this  color  changes  pretty 
soon  into  a  pure  white.  The  margins  remain  indistinct  and  striated;  no 
excavation  and  none  of  the  details  of  the  lamina  cribrosa  are  to  be  seen. 
The  surface  of  the  papilla  usually  rises  a  little  above  the  level  of  its  sur- 
roundings, to  a  fairly  high  degree  when  the  atrophy  is  due  to  choked  disk. 

The  vessels  are  always  changed ;  the  veins  are  tortuous,  engorged  to  a 
greater  or  less  degree,  while  the  arteries  are  smaller  than  normal.  This 
difference  is  particularly  marked  in  old  choked  disk  (see  Fig.  13).  In  the 
majority  of  cases  the  vessels  are  also  accompanied  by  white  stripes. 

Newly  formed  vessels,  which  are  frequently  twisted  like  corkscrews,  or 
formed  into  loops,  are  not  rarely  seen  on  the  papilla ;  opticociliary  vessels 
(see  page  104)   are  also  observed  more  often  than  usual. 

These  phenomena  become  the  more  marked  the  longer  the  inflannnation 
has  lasted.  In  cases  that  run  a  rapid  course  a  neuritic  may  therefore  some- 
times  appear  very  like   a  simple  atrophy,   and  inflammations  that  occur  in 


58 

old  age  arc  apt  to  have  severer  seciiula'  tlian  tliosc  that  affect  younger 
persons. 

The  differences  between  the  atropines  caused  by  inflammation  and  by 
choked  disk  equalize  themselves  in  the  course  of  time,  especially  in  young 
people,  so  that  it  is  sometimes  impossible  to  make  a  differential  diagnosis 
between  these  two  forms. 

Tf  the  inflammation  was  not  confined  to  the  papilla,  but  involved  its 
surroundings,  discolorations  and  partial  vascular  changes  of  particularly 
high  degree  are  iiccustomed  to  appear  as  sefpiehe.  On  tlu'  other  hand,  there 
is  in  many  cases  an  entrance  of  pigment  into  the  atrophic  retina,  as  shown 
in  Fig.   12,  which  causes  an  uncertain  grayness  about  the  optic  nerve. 

Pathologically,  tlic  indistinctness  of  the  margins  of  the  papilla,  as  well 
as  the  stripes  that  accompany  the  vessels,  are  to  be  ascribed  to  a  jiroliferation 
of  the  glia  tissue,  though  the  stripes  along  the  vessels  may  be  caused  in  part 
by  changes  in  the  tissue  of  the  walls  of  the  latter. 

Etiologically,  all  of  those  factors  have  to  be  taken  into  account  which 
can  cause  an  optic  neuritis. 

The  so-called  retrobulbar  neuritis  can  never  cause  a  neuritic  atrophy. 

5.  The  Atrophji  of  the  Papilla  'ni  lietinitis  Pigmentosa  (Fig.  51)  is  to 
be  considered  only  as  one  symptom  of  a  clinical  picture,  but,  as  it  is  usual 
for  the  glance  of  the  observer  to  fall  first  on  the  pa])illa  when  he  is  making 
an  ophthalmoscopic  examination,   its  characteristics  may  be  mentioned  here. 

Retinitic  atrophy  has  a  certain  resemblance  to  the  neuritic  form  in  that 
the  margins  of  the  papilla  are  indistinct :  its  color,  however,  is  conmionlj-  a 
yellowish  gray,  rather  than  a  pure  white. 

What  is  particularly  marked  is  the  great  diminution  of  the  size  of  the 
retinal  vessels,  which  ordinarily  .show  no  changes  in  their  walls ;  in  this  respect 
it  may  resemble  nutritional  ati-ophy,  es])ecially  when  due  to  occlusion  of  the 
central  artery,  but  it  may  be  differentiatid  from  this  by  the  condition  of 
the  margins,  which  usujillv  are  sharply  defined  in  nutritional  atrophy,  indis- 
tinct in  retinitic,  and  by  the  color,  which  is  white  in  the  former,  yellowish 
in  the  latter. 

The  condition  of  the  retina,  especially  in  the  periphery  (see  page  174), 
is  decisive  as  regards  the  diagnosis. 

B.    Partial,  or  Temporal,  Atrophy  of  the  Optic  Nerve 

The  margins,  level,  and  vessels  are  perfectly  normal ;  the  only  variation 
from  the  normal  to  be  seen  is  the  paleness  of  the  temporal  side  of  the  papilla. 
As  large  physiological  excavations  situated  in  this  portion  may  simulate  a 
temporal  paleness  under  certain  circumstances,  and.  on  the  other  hand,  as 
the  temporal  portion  of  the  disk  is  normally  nuch  brighter  th.ui  the  nasal, 
it  is  evident  that  great  care  must  be  exercised  in  making  the  diagnosis. 

If   the   diagnosis    cannot   be   made    positively    from    the    ophthalmoscopic 


59 

picture,  the  field  of  vision  is  to  be  investigated.  If  a  central  scotoma  '  is 
found,  with  the  outer  portions  of  the  field  normal,  which  is  at  first  only  f(jr 
green  and  red,  later  for  white  also,  a  positive  diagnosis  of  partial  atrophy 
may  be  made. 

The  determination  of  the  etiology  is  of  very  great  importance,  as  the 
temporal  paleness  may  be  caused  by  very  different  diseases. 

1.  Chr-onic  iutoxicdtions.  Preeminent  among  these  is  poisoning  with  alco- 
hol and  tolnicco.  It  is  still  a  question  whether  tobacco  alone  can  produce 
such  an  eifect.  Then  follow  the  toxic  effects  of  methyl  alcohol,  lead,  bisul- 
phide of  carbon,  atoxyl,  quinine,  filix  mas,  and  arsenic,  as  well  as  of  auto- 
intoxications, particularly  in  diabetes. 

2.  Multiple  sclerosis.  The  visual  disturbance  caused  by  this  condition 
is  present  in  about  half  of  the  cases  of  multiple  sclerosis,  and  may  precede 
b^'  years  all  other  signs.  Nystagmus  when  the  eyes  are  turned  as  far  as 
possible  to  one  side  or  the  other  is  frequently  present  as  an  accompanying 
symptom,  paresis  of  the  ocular  muscles  are  less  common,  and  an  immobility 
of  the  pupil  is  almost  never  seen  (see  page  54<). 

3.  The  inflammatori/  diseases  of  the  posterior  ethmoidal  cells  and  of  the 
sphenoidal  sinus  may  bring  about  a  similar  picture  through  an  extension  of 
the  inrtammation  to  the  optic  nerve,  or  through  the  influence  of  toxines  some 
time  after  its  subsidence. 

It  follows  from  the  nature  of  the  cause  that  the  disease  regularlv  aff'ects 
both  eyes  in  Case  1,  while  in  Cases  2  and  3  only  one  eye  may  be  affected. 

Pathologically  this  is  to  be  considered  as  a  secondary  atropiiy  of  the 
papillomacular  bundle  of  optic  nerve  fibers,  which  passes  over  the  temporal 
margin  of  the  papilla  and  supplies  the  macula ;  hence  the  central  scotoma. 
The  disease  actually  begins  in  the  ganglion  cells  of  the  retina. 


^  The  stereoscopic  method  of  Haitz   for  the  determination  of  a  central  scotoma 
is  very  simple  and  valuable  (see  page  79). 


PLATE  VI 

Fig.  10.     Simple  White  Atrophy  of  the  Optic  Nerve 
Fig.  11.     Simple  Gray  Atrophy  of  the  Optic  Nerve 


Fig.  10.     Simple  White  Atrophy  of  the  Optic  Nerve 

(Sec  page  5:3) 

When  wc  study  systematically  the  color,  marn^ins,  level  and  vessels  of 
the  jiapilla  wc  see  that  its  color  is  white,  except  for  some  sHppling  which 
indicates  the  apertures  in  the  lamina  cribrosa,  that  its  margins  are  distinct, 
that  its  level  is  the  same  as  that  of  the  retina,  and  that  its  vessels  are  normal. 
Therefore  everything  about  it  is  normal  except  its  color,  so  that,  by  applying 
our  schedule,  we  are  led  to  the  diagnosis  of  simple  atrophy.  Hence  we  have 
to  think  first  of  tabes,  but  in  this  case  the  result  of  the  neurological  exam- 
ination was  negative.  The  history  stated  that  a  stick  had  penetrated  the 
orbit  of  the  patient  at  a  time  when  he  was  stooping,  and  that  the  eye  had 
been  made  blind  innncdiately.  The  diagnosis  therefore  was  atrophy  after 
interru])ti()n  of  conductivity   (see  page  54). 

The  fundus  is  of  the  tesselated  type,  the  retina  is  more  strongly  pig- 
mented in  the  region  of  the  macula,  distinct  reflex  stri.e  are  visible  along 
the  vessels. 

Fig.  11.     Simple  Gray  Atrophy  of  the  Optic  Nerve 

(See  page  53) 

As  in  the  preceding  picture  the  color  of  the  disk  is  the  only  deviation 
from  normal ;  the  margins,  vessels  and  level  are  normal.  The  dark  spots  in 
the  fundus  are  caused  by  the  pigment  in  the  chorioid  showing  through  the 
retina  (tesselated  fundus).  This  patient  had  tabes.  In  the  later  course  of 
the  disease  the  gray  became  brighter,  and  the  vessels  smaller. 


62 


Tab.  6. 


Fig.  10. 


Fi-  11. 


PLATE  VII 

Fig.  12.     Atrophy  after  Inflammation  of  the  Optic  Nerve, 

Neuritic  Atrophy 

Fig.  13.     Atrophy  of  the  Optic  Nerve  after  Choked  Disk 


Fig.  12.     Atrophy  after  Inflammation  of  the  Optic  Nerve, 

Neuritic  Atrophy 

(See  page  57) 

The  papilla  is  white,  its  margins  indistinct,  the  excavation  and  tiu'  mark- 
ings of  the  lamina  crihrosa  are  erased,  the  vessels  are  bordered  hy  white 
stripes. 

The  indistinctness  of  the  papilla  is  due  to  a  proliferation  of  glia  which 
does  not  cease  exactly  at  its  margin  and  fills  the  cavity  of  the  excavation. 
The  stripes  along  the  vessels  are  caused  partly  by  a  proliferation  of  glia, 
partly  hy  changes  in  their  walls  (see  page  58). 

Pigment  has  migrated  into  the  retina,  which  has  been  rendered  atrophic 
by  the  inflammation,  and  has  produced  the  gray  halo  about  the  jiapilla. 

The  cause  of  the  optic  neuritis  in  this  case  was  syphilis,  which  had  been 
acquired  3  years  before. 


Fig.  13.     Atrophy  of  the  Optic  Nerve  after  Choked  Disk 

(See  page  57) 

As  in  the  preceding  case,  the  margins  of  the  papilla  are  indistinct;  it 
can  be  seen  from  the  ring  surrounding  the  disk  how  far  the  swelling  extends 
into  the  retina. 

The  papilla  is  distinctly  elevated,  as  is  shown  by  the  mounting  of  the 
vessels  at  its  margin ;  the  vessels  themselves  show  the  disproportion  in  size 
between  the  arteries  and  veins  characteristic  of  choked  disk. 

The  vision  was  much  impaired  in  this  case.  The  otiier  eye  of  the  patient, 
who  died  of  gliosarcoma  of  the  cerebellum  soon  after  the  completion  of  tho 
picture  is  shown  in  Fig.  25. 


64 


Tab.  7- 


Fig.  12. 


Fig.  13. 


PLATE  VIII 

Fig.  14.     Glaucomatous  Excavation  and  Atrophy 
Fig.  15.     Large  Physiological  Excavation 


Fig.  14.     Glaucomatous  Excavation  and  Atrophy 

(Seu  payc  55) 

The  color  of  the  pjipilla  is  gray  in  the  center,  with  a  gray  green  shadow 
tone  in  tlie  ninrgiiial  i)ortions,  especially  on  the  nasal  side,  which  varies  some- 
what with  tlir  way  in  which  the  mirror  is  held,  and  is  caused  by  the  over- 
hanging of  the  in.iigins.  Tlu'  papilla  is  encircled  by  a  sliarply  defined  scleral 
ring,  to  wiiich  is  added  a  yellowish  gray  ring  wliich  blends  with  its  surround- 
ings in  a  less  distinct  margin  (iialo  glaucomatosus,  see  page  40).  Its  level 
is  much  deeper  tlian  that  of  the  retina.  The  retinal  vessels  are  not  mate- 
rially altered,  but  they  break  off  and  disappear  exactly  at  the  margin  of 
the  disk,  and  from  this  we  conclude  that  the  excavation  is  abrupt  and  extends 
to  the  margin  of  the  nerve. 

Comj)are  with  this  the  pathological  drawing,  Fig.  M  in  the  text. 

The  rest  of  the  fundus  is  uniform  and  sti])pled.  The  vision  in  this  case 
had  fallen  to  one  sixth  of  the  normal,  and  there  was  a  considerable  concentric 
contraction  of  the  visual  field,  particularly  marked  on  the  nasal  side. 


Fig.  15.     Large  Physiological  Excavation 

(See  page  50) 

In  contrast  with  the  preceding  picture  we  see  here  a  narrow  zone  of 
normal  tissue  between  the  margins  of  the  papilla  and  of  the  excavation. 

The  color,  margins  and  vessels  of  the  papilla  are  normal. 

The  vessels  of  the  retina  do  not  stoj)  at  the  margin  of  the  excavation, 
but  can  be  plainly  traced,  although  their  direction  is  changed.  We  conclude 
from  this  fact  that  the  sides  of  the  excavation  are  not  precipitous,  as  in 
the  last  picture,  but  that  thoy  slope  gradually,  like  the  sides  of  a  cup. 

The  holes  in  the  lamina  cribrosa  can  be  seen  very  distinctly  in  the  floor 
of  the  excavation. 

Compare  with  this  the  pathological  drawing.  Fig.  N,  page  56. 


66 


Tab.  8. 


Fig.  14. 


Fie.  15. 


PLATE  IX 

Fig.  16.     Atrophy  of  the  Optic  Nerve  after  Occlusion  of  the 

Central  Artery 

Fig.  17.     Partial,  or  Temporal,  Paleness  of  the  Optic  Nerve 


Fig.  16.     Atrophy  of  the  Optic  Nerve  after  Occlusion  of  the 

Central  Artery 

(Sue    JKlgL'    55) 

The  papilla  is  white,  its  margins  arc  fairly  distinct,  its  level  is  the  same 
as  that  of  the  retina,  its  veins  are  of  apj)roxiinately  normal  size,  its  arteries 
are  tlireatilike. 

In  the  vicinity  of  tlie  optic  nerve  is  to  he  seen  again  un  uneven  coloriiif^ 
of  the  fundus  as  the  consequence  of  an  immigration  of  pigment  into  the 
atrophic  retina. 

In  the  macula  is  to  be  seen,  framed  in  pigment,  a  coronula  of  little  bright 
points,  which  is  characteristic  of  an  occlusion  of  tlie  artery  that  took  place 
at  some  previous  time  (see  page  127). 

The  vision  of  this  eye  was  totally  lost. 

As  a  general  rule  the  arteries  are  completely  empty  of  blood  for  a  few 
days  after  the  occlusion,  and  then  gradually  refill  from  the  ciliary  vessels  by 
way  of  Zinn's  arterial  plexus  (see  page  168).  » 


Fig.  17.     Partial,  or  Temporal,  Paleness  .of  the  Optic  Nerve 

(See  page  58) 

The  margins,  vessels  and  level  of  the  papilla  are  normal,  but  its  temporal 
half  exhibits  an  abnormal  paleness  that  far  surpasses  the  ordinary  difference 
in  color  of  the  temporal  from  the  nasal  portion. 

This  patient  had  at  the  same  time  a  central  scotoma.  The  neurological 
examination  revealed  that  he  was  suffering  from  nmltiple  sclerosis.  The  loss 
of  vision  caused  by  the  central  scotoma  was  the  only  subjective  symptom  of 
which  he  complained.  The  discovery  of  the  temporal  paleness  led  to  the 
neurological  examination  that  disclosed  the  presence  of  this  serious  disease. 


68 


Tab.  9. 


hi",    in 


Fiar.  17. 


Abnormal  Redness  of  the  Papilla.  Optic  Neuritis, 
Retrobulbar  Neuritis,  and  Choked  Disk 


Abnormal   Redness    of  the   Papilla,    Optic   Neuritis,    Retrobulbar 

Neuritis,  and  Choked  Disk 

I.     Redness  of  the  Papilla  by  Itself 

without  any  other  symptom  is  a  condition  that  must  be  considered  with  ex- 
treme care,  just  the  same  as  paleness,  because  the  color  of  the  papilla  varies 
phi/aiologicaUi/  within  rather  wide  limits  and,  moreover,  is  dependent  on 
a  number  of  secondary  factors,  with  which  it  is  necessary  to  be  acquainted 
in  order  to  estimate  correctly  the  influence  they  exert.  A  papilla  always 
appears  redder  in  a  blonde  than  in  a  brunette  fundus ;  it  appears  to  be  redder 
when  the  light  used  is  saturated  with  red  rays,  as  for  example  that  from  a 
kerosene  lamp;  it  looks  rodder  in  young  than  in  old  persons.  It  must  also 
be  remembered  that  a  hyper<-emia  of  the  papilla  may  be  induced  by  a  pro- 
longed examination  with  the  ophthalmoscope,  or  by  severe  accommodative 
efforts  in  hypermetropes  and  presbyopes. 

Aside  from  these  causes,  which  may  be  termed  physiological,  there  is  a 
hyperajmia  which  appears  as  an  accompani/ing  symptom  of  morbid  processes, 
as  in  inflammations  of  the  anterior  and  posterior  segments  of  the  eye,  espe- 
cially in  iritis  and  iridocyclitis,  in  injuries  of  the  eyeball,  in  empj'emata  of 
the  accessory  sinuses,  and  in  such  circulatory  disturbances  as  are  caused  by 
heart  disease,  or  by  tumors  of  the  mediastinum,  although  the  optic  nerve 
itself  is  not  diseased.  The  bearing  of  all  these  possibilities  nmst  be  recog- 
nized and  correctly  estimated  before  a  hypenfmia  can  be  decided  to  be  the 
iorcrunner  of  an  optic  neuritis,  or  of  a  choked  disk.  Finally,  a  particular 
form  that  is  extremely  apt  to  give  rise  to  mistakes,  and  consequently  has 
been  termed  pseudoneuritis,  demands  a  special  consideration. 

Pseudoneuritis  may  appear  with  an  obscuration  of  the  margins  of  the 
disk,  with  engorgement  and  tortuosity  of  the  vessels,  and  even  with  a  slight 
prominence  of  the  papilla,  anil  yet  the  condition  is  not  pathological,  but 
congenital. 

Hypermetropia,  or  hypermetropic  astigmatisni,  is  commonly  present  in 
these  cases,  ana,  as  these  conditions  of  refraction  sometimes  impair  the  vision, 
another  symptom  of  true  optic  neuritis  may  be  added,  viz.,  the  impairment 
of  the  vision.  But  pseudoneuritis  can  be  positively  differentiated  from  optic 
neuritis  by  the  absence  of  the  oedema  about  the  pajiilla.  which  is  present 
in  almost  all  cases  of  optic  neuritis  and  is  always  absent  in  pseudoneuritis. 
The  presence  of  hemorrhages,  or  of  disturbances  in  the  field  of  vision,  renders 
the  diagnosis  of  optic  neuritis  certain,  but  these  symptoms  are  absent  in 
many  cases. 

71 


II.    Optic  Neuritis 

The  difTcrentiiition  of  pseudoneuritis  from  optic  neuritis  is  of  so  much 
the  greater  ini])ort<ince  because  the  hitter  is  an  indication  of  tlic  presence 
of  some  other  <rrave  disease,  usually  of  the  treneral  organism.  Optic  neu- 
ritis is  not  a  disease  per  se,  but  is  to  be  looked  upon  as  a  symptom 
of  another  serious  disease. 

Heme  it  in  our  diit/f  in  cvfry  cattc  of  optic  neuritis  to  asccrtiiin  the  fun- 
damental disease  which  liiix  produced  it.  and,  first  of  all,  to  examine  the  urine 
and  to  test  for  Wasscrmann's  reaction. 

The  case  would  be  parallel  if  we  were  satisfied  witli  the  diagnosis  cough, 
and  did  not  seek  out  the  cause  of  the  cough,  should  we  neglect  to  make  a 
general  examination  of  tlie  organism  when  an  o])tic  neuritis  is  present. 

The  causes  are  manifold  and  may  be  either  general  or  local. 

The  commonest  cause  of  an  optic  neuritis  is  syphilis,  the  next  in  fre- 
quency is  alhuiiiiiiiiriii.  All  other  causes  are  of  secondary  importance.  They 
are  tuberculosis,  diabetes,  the  various  forms  of  basilar  meningitis  due  to 
acquired  or  hereditary  syphilis  or  tuberculosis,  the  acute  infectious  diseases, 
such  as  typhoid  fever,  malaria,  pneumonia,  small  pox,  diphtheria,  scarlet 
fever,  epidemic  cerebros])inal  meningitis,  and  myelitis. 

Among  the  local  causes  may  be  named  suppurative  inflannnation  in  the 
orbit,  in  the  car,  or  in  the  accessory  sinuses  (see  page  78),  abscesses  in  the 
brain,  and  anomalies  in  the  form  of  the  skull,  such  as  oxycephalus. 

It  should  be  noted  that  the  inflammation  excited  by  general  disease  is 
commonly  bilateral,  while  that  due  to  local  causes  is  apt  to  be  confined  to 
one  side. 

Diagnosis. — If  we  follow  our  j)lan  and  study  each  papilla  with  regard 
to  its  color,  margins,  level,  and  vessels,  we  find  the  principal  symptoms  of 
optic  neuritis  to  be: 

1.  Redness   and   cloudiness   of  the   papilla. 

2.  Obscurations  of  its  margins,  peripapillary  (edema. 

3.  I^ittlc  or  no  elevation. 

4.  Little  change  in  the  arteries,  broadening  and  tortuosity  of  the  veins, 
which  sometimes  are  provided  with  accompanying  streaks. 

Note  to  1.  Tlie  redness  is  caused  by  a  congestion  of  the  smallest  vessels 
and  its  signification  has  already  been  considered. 

Note  to  2.  The  clmuliness  of  the  tissue  of  the  papilla,  and  the  obscuration 
of  its  margins,  is  brought  about  by  a  marked  oedema  which  permeates  both 
the  head  of  the  optic  nerve  and  the  adjacent  retina. 

The  peripapillary  oedema  forms  a  reddish  gray,  or  pure  gray  ring,  1  or  2 
papillary  diameters  broad,  wliich  surrounds  the  entrance  of  the  optic  nerve 
and  obscures  the  tissue  that  lies  beneath  and  within  it.  It  is  to  be  seen  most 
plainly  in  an  albinotic.  or  a  tessclatcd  fundus,  because  it  hides  the  markings 


73 

DIFFERENTIAL  DIAGNOSIS  BETWEEN  OPTIC  NEURITIS,  CHOKED  DISK, 

AND  PSEUDONEURITIS 


Color 

Mar^ns 

.Level 

Vessels 

Peripapillary 

CEdema  of  the 

Retina 

Hemor- 
rhaKes  in 
the  Retina 

Vision  and 
Refraction 

Field  of  Vision 

Optic 
neuritis 

abnor- 
mally 
>-     red     i 
and 
cloudy 

par- 
tially 

or 
wholly 

ob- 
scured 

little  or 
no  eleva- 
tion 

arteries  little 
changed ;  veins 
broad  and  tor- 
tuous 

always 
present 

rarely 
present 

usually  much 
inii>aircd 

a  central  scoto- 
ma often 
present 

Choked 
disk 

great 
elevation 

arteries  small, 
veins  enlarged; 

great  dispro- 
jxtrtion  in  size 

between  the 

veins  and  the 

arteries 

always 
present 

usually 
present 

normal  for  a 
long  time,  of- 
ten with  tran- 
sient obscura- 
tions 

variable;  nor- 
mal, concentric 

contraction, 
sectorlike  sco- 
tomas, hemian- 
opsia . 

Pseudo- 
Deuritis 

little  or 
no  eleva- 
tion 

arteries  normal, 
veins  often 
broad  and 

tortuous 

never 
present 

never 
present 

normal,  or  im- 
paired in  conse- 
quence of 
hypernietropia 
or  hypermetro- 
pic astigmatism 

normal 

'  For  albuminuric  choked  disk,  see  page  79. 


Aside  from  the  forms  of  disease  which  even  the  expert  finds  difficult  to  ditferentiate,  the  diag- 
nostic difficulties  that  arise  may  be  avoided  easily  by  proiier  techiii(|ue  and  attention. 

1.  Inaccurate  focussing  upon  the  ophthalmoscopic  picture.  No  one  makes  the  diagnosis 
of  optic  neuritis  more  often  than  a  neo])hyte  in  ophthalmoscopy,  who  has  not  yet  learned  to  accommo- 
date correctly  upon  the  picture  of  the  fundus  and  mistakes  the  papilla,  which  seems  to  him  in- 
distinct because  of  his  faulty  accommodation,  for  one  that  is  pathologically  changed.  Usually  the 
examiner  is  easily  able  to  change  the  indistinct  i)icture  into  a  distinct  one  by  moving  his  head  back- 
iiard  or   forirarrl,  keeping  his  accommodation  unchanged  (see  page  5  •. 

2.  Delicate,  diffuse  opacities  of  the  cornea  and  lens  may  likewise  cause  confusion  by 
making  the  papilla  api)ear  indistinct.  'I'his  errnr  is  e.isiiy  avoided  by  an  examination  of  the  eye  by 
oblique  illumination,  or  by  throwing  light  into  the  ei/e  u-ith  a  mirror,  which  should  be  made  in  every  case 
previous  to  an  attempt  to  see  the  fundus. 

The  source  of  error  is  not  so  easily  to  be  detected  in 

,S.  Diffuse  opacities  of  the  vitreous.  Usually  it  is  extremely  difficult  to  see  these,  but  we 
may  be  aided  if  we  examine  the  peripherv  of  the  fundus,  as  we  alwaj-s  should.  The  cloudiness  and 
obscuration  caused  by  the  oedema  in  optic  neuritis  extends  at  most  one  or  two  papillary  diameters  into 
the  retina,  which  then  assumes  its  normal  character.  The  periphery  of  the  fundus  is  normal  in  optic 
neuritis,  although  it  may  be  obscured  by  opacities  in  the  vitreous.  When  the  latter  are  present, 
together  with  an  optic  neuritis,  we  have  to  take  very  careful  note  of  the  vessels,  of  any  hemorrhages 
that  may  be  present,  of  little  patches  of  degeneration,  and  of  the  condition  of  the  field  of  vision,  as, 
for  example,  of  the  presence  of  a  central  scotoma,  in  order  not  to  err  in  the  diagnosis. 

4.  Detachments  of  the  Retina  that  are  situated  not  too  far  from  the  papilla  may  give  rise  to 
a  confusion  with  a  partial,  or  a  total  optic  neuritis,  through  an  accompanying  oedema  that  reaches  to 
the  papilla,  a  cloudiness  of  the  retina,  and  a  tortuosity  of  the  vessels,  but  this  error  also  may  be 
avoided  by  an  examination  of  the  periphery  and  of  the  field  of  vision  (see  page  lol).  This  possibility 
must  always  be  borne  in  mind. 

5.  Commotio  retinae,  when  it  affects  the  vicinity  of  the  optic  nerve,  may  sometimes  give  rise 
to  an  error  (Fig.  43).  at  l(  ast  at  first  glance.  The  abs<nee  of  involvement  of  the  vessels  and  the  rapid 
disappearance  of  the  trnubli-.  taken  together  with  tlie  liistory,  are  diagnostic. 

6.  The  Cloudiness  of  the  region  of  the  papilla  caused  by  occlusion  of  thi-  central  artery  can 
give  rise  to  this  mistake  only  until  the  cherry  red  spot  has  been  seen  in  the  macula.  It  is  associated 
with  amaurosis,  while  usually  there  is  only  a  great  impairnunt  of  the  vision  in  optic  neuritis  (Fig.  44).» 

7.  The  so-called  supertraction  crescent  of  myopia  (see  Fig;  5  and  page  35)  can  simulate 
at  least  a  partial  optic  neuritis.  The  absence  of  other  syuii)toms  of  this  disease  and  the  demonstration 
of  other  myopic  changes,  such  as  a  conus,  render  the  diagnosis  positive. 


74 

of  the  cliorioiil  tliut  iirv  t'lscwliure  visil  Ic.  It  is  not  always  ;is  distinctly 
iii.\rki.(l  lis  it  is  ill  Vi<^.  22,  in  wliich  case  unusually  favorable  conditions  are 
present;  the  (rdi'Mia  is  pai-ticularly  j;rcat  ami  the  fundus  is  very  rich  ni  details, 
so  that  the  contrast  hitween  the  veiled  and  the  unviiled  parts  is  very  striking. 
The  same  conditions,  to  a  less  deirree,  are  shown  in  Fif^s.  18  20.  Sonutinies 
it  can  he  pei-ci'ivi'd  (Uil\'  from  the  fact  that  a  delicati'  veil  seems  to  be  spread 
over  certain  parts  of  the  retinal  vessels. 

The  inaririns  of  the  optic  nerve  are  obscured  iiy  a  peripapillary  ledenia 
in  of)tic  iiciiriiix,  while  the  same  symptom  is  produced  in  pseudoneuritis  by  a 
copious  (le\elopment  of  the  su|)])ortinif  tissue;  this  is  why  so  much  stress  is 
laid  on  the  demonstration  of  irdema  in  the  diannosis  of  the  forme)'.  In  many 
cases  the  redness  and  cloudiness  of  the  papill.a,  anil  of  its  vicinity,  eaust'd 
by  this  (I'dema  is  so  <rreat  that  both  exhibit  the  same  color,  and  then  the 
(litHcultv  of  distin^'uisliinir  tliim  a])art  is  so  enormous  that  the  position  of 
the  papilla  can  be  recognized  oidy  from  the  confluence  of  the  vessels. 

Note  to  a.  A  distinct  elevation  of  the  jxipillti  is  not  apt  to  be  presint 
in  optic  neuritis,  but  any  excavation  that  exists  may  be  tilled  uj)  by  the 
oedematous  tissue. 

Xote  to  4.  The  veins  alone  are  really  channed;  they  are  broadened  and 
tortuous,  while  the  arteries  usually  retain  a  normal  caliber.  The  determina- 
tion of  this  fact  is  of  im])ortance  in  the  diiferentiation  from  choked  disk.  In 
which  a  marked  disproportion  in  the  fullness  of  the  two  kinds  of  vessels  is 
brought  about  by  the  sinuiltaneous  diminution  in  the  size  of  the  arteries. 
The  vessels  are  not  infrequently  jirovided  with   white  stripes. 

Patches  of  degeneration  and  hemorrhages  are  often  found  near  the  papilla, 
or  in  the  region  of  the  macula,  yet  less  often  than  in  connection  with  choked 
disk.  The  demonstration  of  such  hemorrhages  is  likewise  of  the  greatest 
importance  to  the  diagnosis  of  oj)tic  neuritis  as  they  are  naturally  absent 
in  ])seudoneuritis. 

The  vision  and  the  condition  of  the  visual  Held  are  also  of  great  value. 
In  optic  neuritis  the  vision  is  apt  to  be  very  nuich  impaired  from  the  first, 
as  the  result  of  a  larger  or  smaller,  relative  or  absolute  scotoma,  while  in 
choked  disk  it  is  apt  to  be  normal,  at  least  at  first.  In  pseudoneuritis  the 
vision  is  either  normal,  or  impaired  by  the  associated  refractive  error,  but 
no  anomaly  is  ever  found  in  the  visual  field. 

The  Course  of  Optic  Neuritis.  The  onset  of  optic  neuritis  may  be 
acute  and  may,  in  that  case,  become  fully  developed  in  a  few  days,  or  it  may 
take  a  chronic  form,  when  the  inflammatory  lesion  may  affect  only  a  portion 
of  the  j)aj)illa,  for  example,  its  nasal  half,  and  thence  may  gradually  spread 
to  the  whole. 

A  better  delimitation  of  tlie  papilla  reappears  with  the  subsidence  of  the 
inflammatory  symptoms,  the  hypera'mia  dies  away,  and  only  the  changi-  in 
the  vessels  and  a  smoky  cloudiness  over  the  papilla  and  its  vicinity,  through 
which  the   former  appears   of  a  dull   red  yellow,   remain   as   mementos   of  the 


75 

presence  of  a  morbia  process  (Fif^.  21).  The  functions  return  to  a  ^-eater 
or  less  degree  witli  the  involution  of  the  intianiniatory  symptoms,  hut,  even 
in  the  cases  in  whicli  the  vision  and  the  visual  field  become  quite  normal  again, 
the  papilla  finally  shows  a  whitish,  atropine  discoloration,  which  may  be 
either  total  or  partial.  In  the  cases  in  which  this  discoloration  is  scarcely 
suggested  there  is  still  a  change  in  the  tone  of  color  of  the  j)apilla  from  the 
soft,  delicate,  peachlike  hue.  to  a  hard,  poreelainlike  red,  which  is  more  marked 
on  the  nasal  than  on  the  temporal  side,  where  the  atrophy  is  always  the 
more  distinct.  A  complete  white  discoloration  of  the  ()j)tic  nerve  naturally 
appears  in  the  course  of  time  in  the  cases  in  which  a  greater  functional  trouble 
results.     This  has  already  been  described  on  page  57. 

What  Etiological  Conclusions  can  be  Drawn  from  the  Ophthal- 
moscopic Picture  of  an  Optic  Neuritis? 

It  can  be  seen  in  Figs.  18~22  that,  in  spite  of  the  uniformity  in  the 
essential  points,  the  various  pictures  present  considerable  differences,  and  the 
question  arises  whether  these  differences  may  not  be  utilized  in  ascertaining 
the  etiology.  In  regard  to  this  it  must  be  noted  that  there  are  no  quite 
characteristic  differences,  but  that  certain  points  may  be  utilized  in  one 
way  or  another. 

It  has  already  been  mentiontd  that  the  forms  of  optic  neuritis  caused  by 
general  diseases  are  for  the  most  part  bilateral,  while  those  due  to  local 
lesions  are  usually  unilateral.  Although  this  statement  does  not  hold  good 
absolutely,  yet  it  is  a  guide  to  a  certain  extent.  It  cannot  be  emphasized 
too  strongly  that  we  must  not  be  content  with  the  diagnosis  "optic  neuritis" 
in  our  ophthalmoscopic  examination,  but  nmst  carefully  investigate  the  other 
parts  of  the  eye  in  search  of  [loints  indicative  of  the  etiology  of  the  disease 
of  the  optic  nerve.  If  we  should  fail  to  find  the  hemorrhages  and  white  spots 
characteristic  of  the  albuminuric  form,  which  have  been  described  on  page 
133,  we  have  to  notice  whether  patches  can  be  found  in  the  chorioid  that 
suggest  by  their  appearance  a  syphilitic,  or  a  tuberculous  origin.  ^  ery 
marked  obscuration  of  the  margins  of  the  nerve  is  suggestive  of  syphilis. 

Further  points  may  be  drawn  from  the  following: 

1.  Sf/phUitic  optic  rifuritis  (neuro- retinitis  specifica)  can  often  be  recog- 
nized from  the  presence  of  a  large  oedema,  which  extends  into  the  retina  fen- 
the  distance  of  2  papillary  diameters  and  mav  be  so  dense  as  to  cover  the 
optic  nerve  and  the  retina  with  so  uniform  a  layer  as  to  render  it  impossible 
to  tell  where  the  former  stops  and  the  latter  begins.  In  such  a  case  the 
situation  of  the  papilla  can  be  determined  onlv  from  the  confluence  of  the 
vessels.  Usually  there  is  a  diffuse,  central  opacity  of  the  vitreous  which 
contributes  to  render  the  picture  still  more  oliscure. 

Old  or  fresh  patcher  in  the  chorioid,  with  deposits  of  pigment,  are  fre- 
quently to  be  seen  in  the  j)eripherv.  The  retinal  vessels  also  show  sclerotic 
changes   in  many   cases,  in   I'onNeciiience   of  which    hemorrhages,   arranged    like 


76 

the  spokes  of  a  wheel,  niid  white  spots  are  not  uncommon,  thouijh  mucli  less 
often  present  than  in  alhumiiHiric  ntinitis.  If  the  picture  presents  tins  form 
we  may  he  quite  certain  tiiat  the  case  is  one  of  syphilis.  Only  too  often  we 
do  not  find  these  distinctive  features,  but  see  such  a  picture  as  that  shown 
in  Fig.  18. 

The  extent  of  the  oedema  depends  in  part  on  from  what  place  in  the  optic 
nerve  the  inflammation  starts.  It  may  originate  either  from  the  sheath  of 
the  optic  nerve,  or  from  its  interstitial  tissue.  In  the  former  case  we  see 
the  large  oedema  described  above  (perineuritis),  in  the  latter  the  form  illus- 
trated in  Fig.  18  (interstitial  neuritis). 

As  Wassermann's  test  must  be  made  in  every  case,  it  is  rarely 
that  the  diagnosis  of  syphilitic  optic  neuritis  will  fail  to  be  made. 

It  should  also  be  mentioned  that  a  specific  basilar  meningitis  may  pass 
from  the  meninges  to  the  optic  nerve  and  create  the  picture  of  an  optic 
neuritis.  In  these  cases  we  have  to  expect,  in  addition  to  other  cerebral 
symptoms,  pareses  of  the  ocular  muscles,  which  give  rise  to  diplopia,  paresis 
of  the  accommodation,  mydriasis,  and  iiimiohility  of  the  pupil  to  light,  espe- 
cially on  one  side. 

An  optic  neuritis  due  to  hereditary  syphilis  is  rarely  seen,  and  is  then 
usually  associated  with  meningitis.  As  this  disease  occupies  the  attention 
at  the  time  of  the  acute  symptoms,  the  inflammation  is  observed  only  in 
exceptional  cases,  usually  the  atrophy  alone  is  to  he  seen  (Fig.  58). 

2.  As  a  rule  it  is  not  possible  to  recognize  tuberculous  optic  neuritis  as 
such  from  the  ophthalmoscopic  picture,  unless  tubercles  are  visible  at  the 
time  in  the  chorioid  or  the  optic  nerve,  as  in  Fig.  19.  It  is  met  with  almost 
always  in  children,  or  in  young  people,  and  is  to  be  diagnosed  by  the  exclu- 
sion of  every  other  cause  that  may  produce  an  optic  neuritis  and  the  existence 
of  tuberculous  lesions  elsewhere  in  the  body. 

The  prognosis  is  doubtful;  it  is  bad  as  regards  litV  in  the  cases  in  which 
a  tubercle  is  situated  in  the  optic  nerve  (see  Fig.  19). 

Although  the  primary  inflammation  of  the  optic  nerve  is  the  rule  in 
xi/philis,  and  the  extension  from  the  meninges  forms  the  exception,  the  reverse 
is  true  in  tuberculosis;  the  primary  inflammation  is  very  rare  and  the  trans- 
mitted very  common.  I'hthoff  says  that  it  is  the  most  frequent  ocular  symp- 
tom in  tuberculous  meningitis,  as  it  occurs  in  from  2.5  to  30%  of  all  cases. 

In  spite  of  this  an  atrophy  as  the  result  of  an  optic  neuritis  due  to  a 
tuberculous  meningitis  is  seen  very  seldom,  because  most  of  the  patients  die 
at  an  early  period.  When  an  atrophy  is  found  as  the  consequence  of  a 
"meningitic"  optic  neuritis,  the  cause  of  the  latter  was  probably  a  syphilitic 
meningitis,  as  this  is  not  as  fatal. 

3.  Albuminuric  and  diabetic  optic  neuritis  can  often  he  distinguished  by 
the  early  appearance  of  hemorrhages  and  patches  of  degeneration  in  the  retina 
(Fig.  20).  Usually  the  retina  is  so  much  the  more  aflFected  that  the  neuritis 
retires   to   the  background    (see   Fig.   35)-      I"    many   cases   an    albuminuric 


77 

optic  neuritis  may  liavo  throutjliout  the  appearance  of  a  cliokcd  disk  (see 
page  76). 

A  point  in  the  dift'crenti.il  diagnosis  of  diabetic  optic  neuritis  is  that  the 
accompanying  central  scotoma  is  often  extremely  minute. 

4.  Arteriosclerotic  optic  neuritis  is  characterized  by  a  rather  sluggish 
course  and  more  or  less  distinct  arteriosclerotic  changes  in  the  vessels  of 
the  retina  (Fig.  21)- 

To  make  the  diagnosis  of  arteriosclerotic  optic  neuritis  from  such  a  pic- 
ture is  permissible  only  when  the  morbid  process  is  observed  from  the  start, 


\ 


%  "         -^ 


Fig.  O. — Neuritis  Optica. 

Picture  showing-  the  pathology  of  the  inflamed  optic  nerve,  from  Tioemer's  "Textbook 
of  Ophthalmology."  The  interspaces  between  the  bundles  of  fibers  are  dilated, 
and  the  fibers  themselves,  as  well  as  the  interstitial  tissue,  are  permeated  with 
numerous  lymphocytes. 

and  it  has  been  ascertained  that  this  picttire  represents  the  acme  of  the 
disease ;  otherwise  the  same  picture  could  be  brought  about  by  an  optic  neuritis 
due  to  some  other  cause  which  was  undergoing  involution.  In  exceptional 
cases  an  arteriosclerotic  optic  neuritis  may  also  present  the  appearance  of 
a  choked  disk. 

5.  The  otogenous  optic  neuritis  usually  exhibits  only  engorgement  and 
hyperemia ;  the  vessels  are  changed  only  a  little,  and  there  is  little  redema. 
But,  if  a  complication  is  added  to  the  otitis  in  the  form  of  a  meningitis,  an 
abscess,  or  a  sinus  thrombosis,  the  oedema  increases  very  rapidly  and  such  a 
picture  may  ensue  as  that  shown  in  Fig.  22,  while  it  is  not  necessary  that 
the  functions  be  materially  altered.  It  has  frequenth'  been  observed  that 
the  inflammatory  symptoms  augment  considerably  after  the  opening  of  an  ab- 


78 

scess,  for  example,   hut   tliis  has   no   iinfavorahli>   influeiice  on    the  prof^nosis. 
Under  proper  treatment  it  usually  runs  a  l)enign  course. 

6.  The  forms  of  optic  neuritis  that  are  caused  by  abscesses  in  the  orbit 
and  empficmxis  of  the  accessory  sinuses  show  a  marked  contrast  to  the  otoge- 
nous in  that  the  disturbance  of  vision,  a  central  scotoma  which  is  often  very 
large,  mav  be  (juite  considerable  at  a  time  whiii  scai-crly  anytiiiiiir  wrong  can 
be  seen  on  the  optic  nerve.  The  prognosis  is  usually  good  when  the  diseased 
cavities  are  opened  at  the  proper  time,  yet  it  must  be  made  with  some  reserva- 
tion. Sometimes  these  forms  of  optic  neuritis  resemble  in  their  course  tlie 
axial,  which  is  described  below,  sometimes  a  marked  choked  disk.  In  many 
cases  of  abscess  of  the  orbit  a  thrombosis  of  the  retinal  vessels  is  produced, 
which  can  be  recognized  by  the  deep  black  color  of  the  colunms  of  blood  and 
the  absence  of  the  pressure  pulse  (see  page  107). 

7.  Si/mpatJtctic  optic  neuritis  is  a  very  rare  phenomenon,  but  when  it  is 
met  with  it  is  usually  in  company  with  the  characteristic  roundish  patciies  in 
the   ciiorioid   illustrated   in   Fig.  40. 

8.  No  other  forms  of  optic  neuritis  have  anv  distinctive  characteristics; 
it  is  necessarv  to  relv  whollv  on  the  results  of  the  general  examination  in 
order  to  determine  their  etiology. 

III.  Axial  Optic  Neuritis  ' 

(Neuritis  fasciculi  papillomacularis  ;  Toxic  neuritis;  Retrobulbar  neuritis.) 
An  ophthalmoscopic  picture  of  this  condition  is  not  presented  in  the 
atlas,  because  no  change  is  produced  in  the  appearance  of  the  head  of  the 
optic  nerve  in  95%  of  the  cases  of  the  disease  in  question,  and  in  the  re- 
maining 5^  the  only  change  is  a  little  hypera'mia  and  engorgement,  at  least 
in  the  chronic  cases.  In  acute  poisoning  with  methyl  alcohol  more  marked 
symptoms  are  to  be  seen,  some  resembling  a  partial  atrophy,  some  a  choked 
disk.  Individual  cases  present  an  atroph}'  of  the  head  of  the  optic  nerve 
that  is  demonstrable  on  tiie  third  day.  The  diagnosis  is  possil;le  in  all  chronic 
cases  only  through  the  demonstration  of  certain  subjective  symptoms. 

The  disease  usually  begins  suddenly  with  a  visual  disturbance  which  permits 
the  patient  to  orientate,  but  precludes  the  distinct  perception  of  fixed  objects, 
and  especially  renders  it  impossible  for  him  to  read.  If  he  is  then  examined 
with  the  perimeter,  or  with  Haitz"  charts,  the  demonstration  of  a  central 
scotoma  is  fairh'  eas3^  The  examination  with  colors  is  particularly  impor- 
tant;  the  color  of  small  green  and  red  objects  cannot  be  recognized  centrally, 
but  they  appear  to  be  gray  or  "dark,"  while  it  is  perceived  at  once  by  periphe- 
ral vision,  i.e.,  as  soon  as  the  patient  looks  to  one  side  of  the  object.     The 

'  The  neuritis  may  be  considered  to  be  secondary,  or  ascendincr  in  this  disease, 
the  origin  of  which  is  a  destruction  of  the  ganglion  cells  of  the  retina,  as  has  been 
proved  by  the  pathological  examination  of  persons  poisoned  with  methyl  alcohol  dur- 
ing the  past  year  in  Berlin. 


79 

perception  of  yellow  and  of  blue  is  also  lost  in  the  later  stag's,  hut  the  de- 
monstration of  a  central  scotoma  for  green  and  red  in  the  beginning  is  decisive 
as  regards  the  diagnosis.  The  size  of  the  central  scotoma  is  not  absolutely 
dependent  on  the  extent  of  the  area  of  distribution  of  the  paiiillomacular 
bundle;  it  ma}^  be  smaller  than  this,  as  in  diabetes,  or  it  may  be  considerablj' 
larger  when  the  adjacent  parts  of  the  optic  nerve  are  involved,  especially  in 
diseases  cf  the  accessory  sinuses.  At  first  there  is  usually  nothing  to  be  seen 
with  the  ophthalmoscope;  it  is  not  until  the  process  passes  over  into  atrophy 
that  a  paleness  of  the  temporal  side  of  the  optic  nerve  is  to  be  seen  (see  page 

•58). 

The  same  diseases  are  to  be  taken  into  account  etiologically,  as  in  par- 
tial, or  temporal,  atrophy  of  the  optic  nerve,  diseases  of  the  accessory  sinuses, 
intoxications,  and  multiple  sclerosis  (see  page  .59). 

It  should  be  remembered  that  a  number  of  diseases,  such  as  empyema  of 
the  accessory  sinuses,  lead  poisoning,  and  diabetes,  may  induce  the  picture  of 
either  true  optic  neuritis,  or  of  axial  optic  neuritis. 

The  prognosis  depends  on  the  cause  and  the  stage  of  the  disease. 

When  it  is  possible  to  induce  an  alcoholic  to  abstain  from  liquor  his  vision 
may  return,  otherwise  his  optic  nerves  will  become  permanently  atrophic.  The 
prognosis  is  not  so  good,  though  it  is  not  absolutely  bad,  in  cases  of  poisoning 
with  sulphuretted  hydrogen  and  carbonic  oxide:  it  is  ratlier  better  in  diabetes. 

Note. — The  charts  devised  by  Haitz  are  extremely  useful  for  the  de- 
monstration of  a  central  scotoma.  These  charts  consist  of  symmetrical  halves 
with  graduated  lines  and  can  be  used  in  an  ordinarv  stereoscope.  The  two 
halves  of  the  chart  are  superimposed  by  tlie  action  of  prisms  so  that  they  fuse 
into  a  stereoscopic  picture  and  appear  as  one.  This  enables  the  healthv  eve 
to  maintain  an  accurate  fixation  while  the  other  is  tested  for  the  presence 
of  a  central  scotoma. 

IV.  Choked  Disk 

There  is  as  yet  no  universally  accepted  theory  as  to  the  nature  of  the 
origin  of  choked  disk,  it  is  still  uncertain  whether  it  is  caused  purely  by 
engorgement,  or  by  inflammation. 

This  question  is  of  comparatively  little  importance  to  tlie  clinical  picture 
of  at  least  one  form,  the  so-called  albuminuric  choked  disk.  It  deserves  to  be 
particularly  mentioned,  on  account  of  its  great  etiological  Importance,  that 
in  exceptional  cases  albuminuric  neuritis  may  assume  a  form  that  can  scarcelv 
be  differentiated  from  a  clioked  disk  witli  patches  of  degeneration.  Arterio- 
sclerotic optic  neuritis  also  has  the  appearance  of  a  choked  disk  in  many  cases. 

The  most  essential  points  of  difference  between  an  optic  neuritis  and  a 
choked  disk  consist  in : 

1.  The  behavior  of  the  vessels.  In  clioked  disk  there  is  a  verv  consid- 
erable difference   in   the   fullness   of   tlie  veins   and   of  the  arteries;   the   veins 


80 

are  distended,  the  arteries  contracted,  wliile  in  optic  neuritis  tlie  arteries  are 
almost  normal  and  the  veins  overfilled. 

2.  The  elevation  of  the  juad  of  the  optie  nerve.'  A  choked  disk  is  accus- 
tomed to  rise  more  than  1  nnn,  *i  D,  above  the  level  of  the  retina,  while  a  disk 
that  is  the  seat  of  a  neuritis  seldom  reaches  such  a  height. 

3.  The  beh.ivior  of  the  vision. 

In  optic  neuritis  the  vision  is  usually  much  impaired  at  a  very  early  stage 
(central  scotoma),  while  in  choked  disk  it  may  remain  nearly,  or  (juite,  normal 
for  a  long  time. 

The  course  of  a  choked  disk  is  ;is  follows,  according  to  v.  Miclirl: 
At  fir>t  the  arteries  are  seen  to  become  .small  and  to  be  provided  with 
broad  reflex  stripes  u})on  the  papilla.  The  large  venous  trunks  are  much 
broadened,  tortuous,  of  a  dark  red  color,  and  are  destitute  of  jiulsation. 
The  smaller  veins  become  more  distinct  bcc.-iuse  of  their  greater  fullness. 
The  vessels  in  general,  but  particularly  the  veins,  appear  to  be  bent  and 
broken  on  the  other  side  of  the  margin  of  the  papilla  ;  a  large  number  of 
small  vessels  very  often  become  visible  on  the  pa])illa  itself  (I'ig.  25),  and 
give  it  a  reddish  gray  tone  of  color  that  often  inclines  to  violet.  The  papilla 
forms  a  marked  elevation  with  a  precipitous  descent  to  the  retina,  and  exhibits 
an  increasing  opacity  with  radiating  lines,  which  covers  its  margins,  extends 
out  beyond  them,  and  is  bordered  by  ;i  gray  edge.  The  excavation  may 
persist  for  a  while  (Fig.  24),  or  only  a  part  of  the  papilla  may  be  affected 
(Fig.  23)-  In  its  further  course  the  elevation  and  swelling  of  the  pay)illa 
increases,  the  retina  in  its  immediate  neigliborhood  becomes  more  and  more 
opaque,  and  consequently  gives  the  impression  that  the  papilla  has  become 
broader,  because  as  the  result  of  its  indistinct  contour  its  margins  seem  to 
lie  where  the  opacity  ceases.  The  opacity  of  the  papilla  and  of  its  immediate 
vicinitv  exhibits  more  and  more  a  striated  and  reddish  white  appearance  cor- 
responding to  the  normal  course  of  the  bundles  of  nerve  fibers  in  the  retina. 
Often  the  vessels  can  scarcely  be  perceived  in  the  center  of  the  papilla,  but 
come  into  view  first  in  its  periphery,  or  at  the  margin  of  the  opacity,  from 
the  swollen  tissue.  The  arteries  appear  to  be  still  more  contracted  than  at 
first,  drawn  out  and  ])ale.  the  veins,  beginning  with  pale,  pointed  ends,  show 
a  deep,  dark  red  color,  have  diameters  tliat  vary  a  great  deal  according  to 
the  depth  at  which  they  are  situated,  and  l)i'nd  about  with  great  windings  in 
the  plane  of  the  retina,  in  which  they  run  tortuous  courses.  Frequently  the 
vessels  ai-e  hidden,  or  obscured,  for  a  distance  by  a  gray  opacity,  and  hemor- 
rhages are  often  found  arranged  in  radi.il  stria',  usually  in  the  retina  at  the 
margin  of  the  p;ipilla,  as  well  as  here  and  there  in  the  latter  itself.  Fine, 
brilliant  white  lines,  ordinarily  arranged  radially,  on  and  also  outside  of 
the  papilla,  or  small,  brilli-mt  white  spots,  which  appear  at  a  very  early 
period,  are  chiefly  to  be  observed  in  cliildi'en  or  young  people.  These  lines 
and  spots  often  extend  beyond  the  margin  of  the  papilla  and  maintain  such 

'  Coneerninfr  the  way  to  estimate  ditTcrences  of  level,  see  page  9. 


81 

an  extent  and  groupiiitr  tliat  tlio  retina  may  present  the  same  condition  as 
in  albuminuric  retinitis.  Sometimes  the  veins  are  accompanied  by  white 
stripes. 

Gradually  tlic  papilla  loses  its  reddish  tone  of  color,  which  is  replaced  by 
a  white,  or  yellowish  white  opacity,  inclining  to  gray,  but  its  margins  remain 
obscured  and  the  swelling  continues  to  be  plainly  demonstrable.  The  onset 
of  these  changes  ushers  in  the  so-called  atrophic  stage  (Fig.  13)  of  clioked 
disk,  in  which  the  protrusion  of  the  papilla  subsides.  The  opacity  and  swell- 
ing do  not  undergo  complete  involution,  the  arteries  remain  small,  the  veins 
engorged.  Just  as  only  one  half,  or  one  sector,  may  be  swollen  at  first 
(Fig.  23),  so  in  the  involution  of  the  swelling  the  subsidence  may  take  place 
in  the  same  way.  Not  infrequently  the  pigment  epithelium  in  the  region  of 
the  opaque  margin  of  the  optic  disk  is  decolorized. 

What  Etiological  Conclusions  can  be  Drawn  from  the  Ophthal- 
moscopic Picture  of  Choked  Disk? 

Unilateral  Cliol'id  Dislc 

occurs   in   affections    of   the   orbit,    such    as   tumor,   abscess,   cysticercus,    and 

gumma,  and  in  diseases  of  the  accessory  sinuses.     It  must  be  remembered  that 

tumors  or  abscesses  in  the  middle  fossa  of  the  skull  may  protrude  into  the 

orbit. 

Bilateral  Chohed  Disk 

occurs  in  all  conditions  of  the  brain  that  reduce  the  amount  of  space  in  the 
cranial  cavity.  Chief  among  these  are  all  kinds  of  tumors  of  the  brain. 
including  not  only  the  true  tumors,  but  also  cysticerci,  aneurysms,  gum- 
mata,  and  tubercles  (about  70  to  80"^).  Choked  disk  is  absent  in  onh' 
from  .5  to  10%  of  the  cases  of  tumor  of  the  brain,  and  these  are  mainly 
tumors  of  the  frontal  brain  and  of  tlie  hypophysis.  The  fartiier  back 
the  tumor  lies  the  more  certain  is  a  choked  disk  to  appear.  A  very  rapid 
onset  of  visual  disturbance,  with  a  high  degree  of  choked  disk  and  severe 
pains  in  the  back  of  the  head,  is  indicative  of  a  gumma  in  the  cerebellum ;  a 
clioked  disk  with  disturbances  of  the  auditory  and  facial  nerves,  of  a  tumor 
in  the  angle  between  the  cerebellum  and  the  pons.  A  disturbance  in  the 
field  of  vision,  like  a  hemianopsia,  frequently  gives  an  indication  as  to  the 
situation  of  the  tumor.  A  choked  disk  with  horizontal  hemianopsia  may  bo 
caused  by  a  hydrocephalus  internus  with  a  bulging  outward  of  the  recessus 
infundibuli  and  pressure  of  the  same  upon  the  chiasm.  A  localization  of  a 
brain  tumor  from  the  greater  development  of  the  choked  disk  in  one  eye  or 
the  other  cannot  be  made,  but  it  may  perhaps  be  possible  from  the  accom- 
panying faults  in  the  field  of  vision,  such  as  a  homonymous  hemianopsia. 

The  cause  of  choked  disk  next  in  importance  to  tumor  of  the  brain  is 
serous  meningitis,  or  h/jdroccphalus  internus.     None  of  the  other  causes,  such 


82 


as  oxjccphalia,  abscess  of  tlio  hrain,  sinus  tluomljosis,  and  liLinorrliagic 
pachymeningitis,  art'  of  iqual  c'oiisi([iuiice.  In  the  disease  last  mentioned  the 
choked  disk  is  sometimes  unihiteral  and  associated  witli  dilatation  of  the  pupil. 

The  affections  of  the  optic  nerve  observed  in  hemorrhages  into  the  sub- 
dural, or  subarachnoidal  space,  do  not  correspond  entirely  with  the  {)ieturc 
of  choked  disk,  inasnuieh  as  the  dispropoi'tion  between  tiu  ai-terii's  and  the 
veins  is  not  apt  to  be  so  marked.  The  aft'ection  is  usually  more  ])ron()uneed 
on  the  side  of  the  lesion  than  on  the  other. 

Finally,  a  choked  disk  may  result  from  an  obstruction  to  the  outflow  of 


Fig.  p.— Choked  Disk. 

In  this  picture,  taken  from  the  textbook  by  Roemer,  the  mushroomlike  elevation  of 
the  papilla  into  the  vitreous,  and  the  great  distention  of  the  sheath  of  the  optic 
nerve,  are  to  be  seen  very  distinctly. 

the  venous  blood  into  the  cavernous  sinus.  Concerning  the  thrombosis  of  the 
vessels  of  the  retina  see  pages  78  and  102.  Such  a  cause  is  supposed  to 
be  present  in  the  choked  disk  of  chlorosis. 

In  conclusion  it  remains  to  be  said  that  albmninuric  and  arteriosclerotic 
optic  neuritis  may  present  the  picture  of  choked  disk,  in  consequence  of  the 
engorgement  that  takes  place  at  the  same  time.  Therefore  the  urine  should 
be  examined  and  Wassermann'.i  test  he  made  in  every  case. 

The  vision  may  remain  normal  for  a  long  time,  and  therefore  be  at  variance 
with  the  great  ophthalmoscopic  changes.  When  the  choked  disk  passes  into 
the  atrophic  stage  the  vision  gradually  disappears,  but  from  the  first  the 
patients  are  tormented  by  temporary,  fleeting  attacks  of  blindness,  or  of 
obscuration. 


83 

The  field  of  vision  shows  various  forms  of  contraction.  Tlic  defects  may 
be  peripheral,  or  in  the  form  of  sectors,  or  of  hemianopsia,  but  such  a  central 
scotoma  as  accompanies  oj)tic  neuritis  is  almost  never  seen. 

Tumors 

are  rarely  met  with  on  the  papilla ;  the  most  common  are  gummata  and 
tubercles.     A  conglomerate  tubercle  is  shown  in  Fig.  19. 

Sometimes  developments  of  connective  tissue  are  seen  to  extend  out  from 
the  papilla;  these  may  be  the  remains  of  fetal  structures,  the  results  of 
injuries,  or  the  products  of  organization  of  hemorrhages. 

Hemorrhages  on  the  Papilla 

may  appear  in  optic  neuritis,  or  in  choked  disk,  or  when  the  vessels  of  the 
retina  are  sclerotic.  Sometimes  they  result  from  injuries  to  the  .eye,  or  to 
the  optic  nerve. 

Tlie  demonstration  of  a  hemorrhage,  when  it  is  not  of  traumatic  origin, 
is  always  of  great  diagnostic  importance.  For  example,  it  immediately  decides 
the  question  in  a  doubtful  case  of  optic  neuritis  or  pseudoneuritis  in  favor 
of  the  former  (see  page  71). 

]\  our, (Is  of  tlie  Optic  Nerve 

in  the  orbit  produce  an  ophthalmoscopic  picture  that  varies  accordingly  as 
the  nerve  is  severed  in  the  portion  that  contains  the  vessels,  or  in  the  part 
that  does  not.  In  the  former  cases  the  signs  of  an  occlusion  of  the  central 
artery  are  present  (see  Fig.  44,  ;uul  page  150).  in  the  latter  case  the  optic 
nerve  appears  to  be  perfectly  normal  in  spite  of  the  blindness,  until  atrophy 
gradually  develops,  in  the  course  of  about  6  weeks  (see  Fig.  10,  and 
page  54). 


PLATE  X 

Fig.  18.     Optic  Neuritis 
Fig.  19.     Tubercle  at  the  Entrance  of  the  Optic  Nerve 


Fig.  18.     Optic  Neuritis 

(See  pages  72  and  75) 

The  margins  of  tlic  optic  disk  arc  quite  indistinct,  tlic  disk  itself  is  much 
reddened  and  is  surrounded  by  a  gray  areola,  due  to  a'dema.  The  veins  are 
much  distended  and  are  slightly  hazy  in  the  gray  zone  caused  by  the  retinal 
oedema.  They  are  acconijj.uiicd  l)y  whitish  stripes  on  the  papilla.  A  slight 
elevation  of  the  disk  can  be  made  out  by  parallactic  displacement,  or  by  de- 
termining the  refraction  with  the  ophtiialmoscope.  Tiie  condition  was  due, 
in  this  case,  to  syphilis. 

The  gray  ring  about  the  papilla  is  of  sjx'cial  value  in  the  diagnosis  (see 
page  72). 

Fig.  19.     Tubercle  at  the  Entrance  of  the  Optic  Nerve 

(See   pages   76   and   83) 

The  larger  part  of  the  papilla  is  obliterated,  its  margin  on  one  side  is 
completely  hidden.  At  that  jjlace  is  a  whitish  mass,  nearly  as  large  as  the 
papilla,  which  is  shown  by  j)arallactic  disj)lacenicnt  to  be  distinctly  elevated. 
It  is  surrounded  by  a  slightly  gray  discoloration  of  the  fundus,  caused  by  an 
a'dema  of  the  retina.  The  retinal  vessels  that  end  at  this  place  y)lunge  into 
the  mass  and  their  terminal  portions  are  invisible.  It  is  striking  that  no 
superior  temporal  artery  cm  l)e  seen.  The  fundus  is  of  the  albinotic  type 
and  is  normal,  except  for  the  gray  discoloration  in  the  vicinity  of  the  lesion; 
the  retinal  vessels  elsewhere  are  normal. 

The  diagnosis  in  this  case  was  that  of  a  tumor  at  the  entrance  of  the  optic 
nerve.  The  specific  diagnosis  of  a  tubercle,  or  of  a  conglomerate  of  tubercles, 
in  the  head  of  the  optic  nerve,  was  based  upon  the  local  reaction  that  followed 
an  injection  of  tuberculin. 


8fi 


Tab.  lO. 


Fig.  18. 


Fig.  19. 


PLATE  XI 

Fig.  20.     Albuminuric  Optic  Neuritis   (Albuminuric  Choked 

Disk) 

Fig.  21.     Optic  Neuritis  Undergoing  Involution 


Fig.   20.     Albuminuric  Optic  Neuritis    (Albuminuric  Choked 

Disk) 

(See  page  7G) 

Tlic  papilla  is  very  red  and  swollen,  its  margins  arc  obliterated,  its  arteries 
reduced  in  size.  It  was  mistaken  at  first  for  a  choked  disk  caused  by  a  tumor 
of  the  brain,  but,  as  the  result  of  the  neurological  examination  was  negative, 
and  the  urine  presented  the  characteristics  of  chronic  nephritis,  that  diagnosis 
liad  to  be  abandoned  and  replaced  by  that  of  an  albuminuric  neuritis  (sec 
page  79).  At  some  distance  from  the  papilla  may  be  seen  hemorrhages 
phiced  radially,  therefore  superficial,  and  some  stipplings  that  indicate  patches 
of  degeneration  on  the  temporal  side.  These  patches  of  degeneration  are  not 
inconsistent  with  a  typical  choked  disk,  for  the}'  arc  sometimes  found  in  asso- 
ciation with  it,  but  they  are  to  be  seen  more  commonly  with  neuroretinitis 
albuminurica. 

The  fundus,  which  is  on  the  whole  of  the  uniform,  stipjiled  type,  approaches 
the  tessehited  in  its  nasal  portion. 

Tile  absence  of  the  stellate  figure  in  the  iiiaculn  is  in  no  way  contraiiidi- 
cative  of  albuminuria,  for  it  is  present  in  by  no  means  all  cases  of  albuminuric 
diseases  of  the  retina. 

Fig.  21. — Optic  Neuritis  Undergoing  Involution 

(See   pages   7-i   and   76) 

The  margins  of  the  papilla  have  already  become  rather  more  distinct.  The 
color  is  a  cold  red  in  the  center,  while  the  marginal  portions  are  paler.  The 
vessels  are  distinctly  sheathed.  Pigment  has  migrated  into  the  retina  around 
the  optic  nerve,  which  accounts  for  the  dark  gray  discoloration. 

Such  a  picture  as  this  may  also  be  indicative  of  the  so-called  arterioscle- 
rotic optic  neuritis,  a  form  of  inflammation  of  the  optic  nerve  that  is  met  with 
in  old  people,  and  is  characterized  by  a  verj'  sluggish  course  of  little  intensity, 
in  which  the  changes  in  the  retinal  vessels  stand  in  the  foreground. 


88 


Tab.  II. 


Fig.  20. 


Fig.  21 


PLATE  XII 

Fig.  22.     The  Optic  Nerve  in  a  Case  of  Sinus  Thrombosis  Com- 
plicating an  Otitis  Media 


Fig.  22.     The  Optic  Nerve  in  a  Case  of  Sinus  Thrombosis  Com- 
plicating an  Otitis  Media 

(See  piigc-  77) 

A  slitrlit  liypei-.Tiiiia  of  tlic  papillu  is  soiiictinu's  seen  in  iincomplic.itcd  cases 
of  otitis  media,  but  as  soon  as  a  ciTcbral  complication  takes  place,  such  as  a 
sinus  tlironibosis,  an  extradural  abscess,  or  a  meningitis,  the  redness  of  the 
papilla  becomes  greater  without  causing  the  margins  to  become  particularly 
indistinct.  The  veins  show  only  a  trifling  congestion.  What  is  specially  no- 
ticeable is  the  enormous  (rdema  of  the  retina  which  surrounds  the  head  of  the 
optic  nerve  and  hides  evirything  that  lies  beneatli  it.  The  retinal  vessels 
may  rise  through  the  (edema  and  show  a  distinct  parallactic  displacement; 
when  they  are  placed  more  deeply  they  are  partially  covered  by  the  oedema, 
as  is  the  case  with  the  vessel  situated  above  in  the  picture. 

The  (edema  is  very  clearly  visible  in  this  case  because  it  is  quite  extensive, 
and  because  tlie  almost  albinotic  fundus  shows  up  many  details  that  are  lack- 
ing in  the  o'deniatous  portion.  The  wdema  cannot  be  seen  as  well  when  the 
color  of  the  fundus  is  uniform. 

As  soon  as  changes  that  are  to  some  degree  distinct  have  appeared  in  the 
head  of  the  optic  nerve  it  becomes  the  duty  of  the  aural  surgeon  to  open  thq 
skull.  This  operation  is  sometimes  followed  by  an  exacerbation  of  the  intra- 
ocular condition,  but  the  prognosis  of  this  is  not  bad. 


90 


Tab.  12. 


Fig.  22. 


PLATE  XIII 

Fig.  23.     Commencing  Choked  Disk 
Fig.  24.     Commencing  Choked  Disk 


Fig.  23.     Commencing  Choked  Disk 

(Sl'u  pa^re  80) 

It  is  important  to  be  rJilc  to  recognize  tiie  early  stage  of  a  clioked  disk 
on  account  of  its  significance  in  diagnosis. 

It  can  be  seen  from  the  course  of  the  vessels  that  the  temporal  portion  of 
the  papilla,  where  the  nerve  fibers  are  feebler,  has  not  yet  been  driven  for- 
ward, while  the  nasal  is  distinctly  elevated.  The  oedema  that  causes  the  ele- 
vation has  already  invaded  the  vicinity  so  as  to  make  the  papilla  appear  to 
be  enlarged  and  to  completely  obscure  its  margins.  The  veins  are  distended, 
while  only  a  part  of  the  arteries  show  tliat  their  caliber  is  diminished. 


Fig.  24. — Commencing  Choked  Disk 

(See  page  80) 

This  picture  shows  another  form.  The  entire  periphery  is  protruded, 
while  the  center  still  remains  at  its  old  level.  The  disproportion  between  the 
arteries  and  the  veins  is  clearly  marked,  as  well  as  the  oedema  that  surrounds 
the  papilla. 


92 


Tab.  1». 


Fig.  23. 


Fig.  24. 


PLATE  XIV 

Fig.  25.     Old  Choked  Disk  with  a  Very  Abundant  Development 

of  Vessels 

Fig.  26.     Choked  Disk  at  Its  Acme 


Fig.  25.     Old  Choked  Disk  with  a  Very  Abundant  Development 

of  Vessels 

(Sec  page  81 ) 

Two  forms  of  cliokc'd  disk  can  be  distin^iished  in  well-marked  cases,  one 
distinctly  knob-shaped,  the  other  more  diffuse.  The  former  is  shown  in  this 
picture. 

The  delimitation  of  the  swollen  portion  from  the  retina  is  comparatively 
tlistiiict.  althoiiirji  the  protrusion  is  considerable,  as  may  be  seen  from  the 
course  of  the  \essels.  and  (edema  is  also  certainly  present.  The  disproportion 
between  the  arteries  and  tlic  \eins  forms  the  principal  ground  for  the  diagnosis. 

On  the  papilla  are  to  l;e  seen  a  large  number  of  newly  formed  vessels;  this 
indicates  that  the  choked  disk  has  lasted  a  long  time. 

The  oilier  papilla  of  the  same  patient,  which  was  distinctly  atrophic,  is 
shown  in  Fig.  22. 

The  lesion  in  this  case  was  a  ii'liosarcoma  of  the  eei'(l)elluni. 


Fig.  26.     Choked  Disk  at  Its  Acme 

(See  page  80) 

The  more  diffusi'  foi'in  is  shown  in  this  picture.  Scarcely  a  trace  can  be 
seen  of  the  margins  of  the  j)apilla.  hut  the  latter  seems  to  send  tonguelike 
processes  into  the  retina.  The  ])aj)illa  is  distinctly  elevated,  as  can  be  seen 
from  the  course  of  the  vessels,  and  exhibits  a  radiating  striation.  A  num- 
ber of  hemorrhages,  also  striate  in  form,  give  the  disk  quite  a  specific  appear- 
ance. The  disproportion  between  the  arteries  and  the  veins  is  so  great  at  the 
acme  that  tiie  former  are  scarcely  visible,  while  the  latter  leave  the  papilla 
as  broad,  tortuous  bands.  Some  white  patches  of  degeneration  are  visible  in 
the  retina.  There  ai'e  only  a  few  retinal  hemorrhages  in  this  case,  but  they 
are  often  much  more  numerous. 

The  vision  in  this  ])atient  was  normal.  The  neurological  examination 
revealed  the  existence  of  a  tumor  in  the  angle  between  the  cerebellum  and  the 
pons,  the  so-called  acusticus  tumor. 


94 


Tab.  J4. 


Fio.  25. 


¥U'.  26. 


Vessels  of  the  Retina 


Vessels  of  the  Retina 

Tlie  great  diagnostic  inipoi-tanci'  of  changes  in  the  vessels  of  tlic  retina 
has  already  been  pointed  out  in  the  study  of  the  diseases  of  the  optic  nerve. 
Nowhere  else  in  the  hodv  can  the  lilood  vessels  be  seen  so  clearly,  nowhere 
else  are  they  so  accessible  to  direct  observation,  nowhere  else  is  our  duty  so 
imperative  to  study  the  minutest  details  of  the  picture,  as  in  the  vessels  of 
the  retina,  the  more  so  that  they  are  offshoots  from  the  vessels  of  the  brain, 
and  that  certain  conclusions  can  be  drawn  from  their  condition  with  refer- 
ence to  that  of  the  cerebral  vessels.  Bouchut  termed  ophthalmoscopy  direct 
cerebroscopy,  and,  although  this  expression  overshoots  the  mark,  it  indicates 
how  highly  ophthalmoscopy  is  to  be  valued   (compare  page  153). 

A  special  chapter  is  devoted  here  to  changes  in  these  vessels  in  order  to 
indicate  their  importance  in  the  most  forceful  manner,  and  to  lead  to  their 
careful  observation. 

In  many  cases  the  sequela  of  diseases  of  the  vessels  stand  forth  in  such  a 
manner,  as,  for  example,  in  Fig.  44,  that  a  certain  schooling  is  needed  to 
think  of,  and  correspondingly  to  investigate,  the  cause  of  such  changes ;  in 
others,  as  in  Fig.  28.  the  changes  in  the  vessels  themselves  are  so  prominent 
that  they  explain  tjie  clinical  picture.  Wc  should  therefore  not  he  content  to 
cast  a  brief  glance  at  the  papilla  in  an  ophthalmoscopic  examimition,  but 
shauld  accustom  ourselves  to  investigate  the  vessels  of  the  retina  very  thor- 
oughly. 

The  changes  relate  chiefly  to  the  caliber  and  walls  of  the  vessels,  more 
rarely  to  their  contents,  and.  uiukr  certain  circumstances,  pulsatory  phe- 
nomena are  to  be  taken  into  account  tliagnostically. 

Preliminary  Remarks  on  the  Anatomy 

It  must  he  remembered  that  tlie  walls  of  the  retinal  vessels  are  perfectly 
transparent,  and  therefore  invisible,  when  they  are  in  a  normal  condition: 
also  that  under  some  pathological  conditions,  as,  for  example,  in  hyaline  de- 
generation, they  may  be  perfectly  transparent  in  spite  of  a  considerable  thick- 
ening that  is  made  evident  only  by  a  narrowing  of  the  blood  column.  Tlm^ 
what  is  seen  ophthalmoscopically  is  not  the  entire  vessel,  but  only  its  eon- 
tents  ;  the  wall  has  to  be  added  mentally,  so  that  the  vessel  is  really  twice  as 
thick  as  it  appears  to  be  in  the  ophthalmoscopic  picture. 

On  the  other  hand,  defects  a])pear  in  the  transparency  of  the  vessel  wall 
which  may  be  observed  in  all  ilegrees,  from  a  scarcely  perceptible  veiling  to  a 

07 


98 

coiiipk'tc  opacity.  Tlio  color  ussiiiiud  \)\  tlic  noscI  may  then  he  a  j)urc  wliitc, 
a  »'rav  wliitc,  ii  yellow  white,  or  a  liirht  hrown ;  lioth  the  o|)acity  and  the 
reflection  iiwiy  be  fairly  variable. 

In  the  observation  of  the  transverse  iliainetcr  of  the  vessel  the  observer  is 
subject  to  many  illusions,  which  are  due  not  only  to  the  optical  conditions 
presi'iit  in  the  eve,  but  also  to  thi'  more  or  less  dee[)  situation  of  the  vessel  in 
the  retina.  The  apparent  size  of  the  ])apilla  must  serve  as  the  unit  of 
measure. 

The  Changes  in  the  Vessels  of  the  Retina 

take  place  in 

A.  The  caliber:     T^ifferentiation  must  be  made  between 

1,  Contractionn,  up  to  total  disappearance  of  the  vessels, 

2,  Diliifiitions, 

3,  Dijfcrciiccs    in    the    projiortioinitc    ciililiir    of    the    arteries    and    of 
the  veins, 

■i,   Vncvcrnuxscs  in  the  caliber  of  individual  vessels. 

B.  The  color:     Tlie  chancre  of  color  may  be  tlue  to 

(a)  the  color  of  the  blood  column, 

(b)  the  color  of  the  k'iiU  of  the  vessel;  in  regard  to  this  are  to  be  noted 

1,  accompanying  stripes, 

2,  transformation  into  white  cords, 

3,  infiltrates  in  or  over  the  vessels. 

C.  The  number  and  arrangement. 

D.  The  course;   drawn  out,  tortuous,  wavy,  broken. 

E.  The  reflex;  its  breadth  and  intensity. 

F.  The  phenomena  of  pulsation. 

ELABORATION  OF  THE  ABOVE  SUMMARY 
A.    The  Caliber 

1.   ConiracHon. 

A  change  in  the  length  of  a  vessel  is  usually  associated  with  a  decrease 
of  its  transverse  diameter;  at  first  it  is  drawn  out,  later  it  is  distinctly  short- 
ened.    The  refiex  and  the  color  are  also  apt  to  be  changed. 

Four  forms  are  to  be  distinguished  ctiologically : 

(n)    That  which  is  produced  pathologically,  commonly  termed  sclerosis; 

(?>)  that  which  is  functional,  caused  by  contraction  of  the  muscular  tissue 
in  the  wall  of  the  vessel ; 

(r)  that  which  is  due  to  compression,  the  cause  of  which  is  to  be  sought 
in  a  compression  of  the  afferent  vessels  ; 

(J)    that  which  is  due  to  an  imperfect  filling  of  the  vessels  with  blood. 


99 

The  first  form,  .sclurosis,  is  tliu  most  coimiion.  x\s  appears  from  tlie  above 
remarks  on  tlie  anatomy,  the  contraction  is  usually  only  an  apparent  one; 
of  such  a  nature  that  the  transjjarciit,  and  therefore  invisible,  wall  of  the 
vessel  is  thickenetl  so  as  to  render  the  blood  tohunn  within  it  smaller,  but  true 
diminutions  and  atrophies  of  the  vessels  themselves  are  met  with.  It  is  not 
usually  possible  to  distinguish  the  two  forms  opiitliahnoscopifully. 

As  considerable  differences  occur  normally  in  the  caliber  of  the  vessels  in 
different  persons,  and  as  the  vessels  in  the  same  person  vary  in  size  one  from 
another,  it  is  often  quite  difficult  to  determine  whether  a  commencing  sclerosis 
is  present  or  not.  In  such  doubtful  cases  attention  has  to  be  paid  to  fiuctua- 
tions  in  caliber,'  to  abnormally  distinct  pulsation,  and  to  the  sheathings  that 
may  perhaps  be  present.  These  conditions  are  almost  always  to  be  held  to 
indicate  a  commencing  sclerosis  of  the  vessels,  the  extremely  rare  congenital 
sheathings  being  excluded. 

If  the  sclerosis  is  more  advanced,  for  example,  as  in  Fig.  67,  no  further 
difficulties  are  encountered  in  its  diagnosis.  As  may  be  seen  in  Fig.  56,  the 
change  may  go  so  far  as  to  render  the  vessels  no  longer  visible. 

The  changes  may  take  place  in  both  the  arteries  and  the  veins,  cither  in- 
dependently of  each  other,  or  together.  In  the  latter  case  the  physiological 
difference  in  the  breadth  of  the  veins  and  the  arteries  is  maintained  to  the  last, 
so  that  when  the  vessels  disappear  the  arteries  are  the  first  to  become  invis- 
ible. In  the  majority  of  cases  the  arteries  alone  are  affected,  while  the  veins 
at  first  seem  to  be  rather  broadened  on  account  of  the  elasticity  of  their 
walls. 

As  complications,  or  sequela?,  may  be  named  atrophy  of  the  optic  nerve 
(see  page  53  and  Fig.  Q),  acute  occlusion  of  the  arteries  with  its  consequences 
(see  page  1.50  and  Fig.  44),  thrombosis  of  the  veins  (see  page  117  and  Fig. 
27),  iind  extensive  disease  of  the  retina  in  the  form  of  retinitis  albuminurica 
(see  page  133  and  Fig.  31),  or  diabetica  (see  page  131-  and  Fig.  35). 

Etiologically,  the  first  disease  to  be  taken  into  account  is  syphilis, 
either  acquired  (Fig.  38)  or  hereditary  (Fig.  56),  then  arteriosclerosis 
(Fig.  67),  chronic  nephritis  and  diabetes.  The  high  degree  of  contraction  of 
the  vessels  found  in  retinitis  pigmentosa  (Fig.  51),  which  afifects  both  the 
arteries  and  the  veins,  depends  on  similar  causes  to  all  appearance.  Contrac- 
tion of  the  arteries  alone  is  to  be  observed  as  a  sequel  of  an  old  occlusion 
(Fig.  16),  and  sometimes  also  in  old  cases  of  glaucoma. 

A  uniform  functional  contraction  of  both  the  arteries  and  the  veins  is 
found  in  cases  of  poisoning  with  quinine  or  ergotin,  in  chronic  alcoholism  and 
in  commencing  syncope. 

A  compression  of  the  arteries  is  associated  regularly  with  a  compression 
of  the  veins,  but  while  it  shows  itself  in  the  arteries  by  a  diminution  of  the 
blood  column  due  to  an  insufficient  supply  of  blood,  it  causes  an  engorgement 

^  The  apparent  diminution  of  the  vessel  to  a  point  at  the  place  where  it  leaves  the 
papilla  is  not  to  be  understood  as  a  fluctuation  in  caliber  in  this  sense. 


100 

of  the  veins  by  obstructing  tlic  escape  of  tlie  blood.  We  iiuct  uitli  coniprcs- 
.sion  cbicfly  in  cases  of  tumor  of  the  orbit  and  affections  that  ri(hiee  the  space 
within  tile  skulh  In  tiie  former  it  is  unilateral,  in  the  latter  bilateral.  As  the 
venous  entjorgenient  forms  tlie  most  conspicuous  jiart  of  the  picture,  this  con- 
dition will  be  described  below,  under  Dilatation  of  the  \'es.sels. 

A  contraction  of  the  arteries  takes  place  in  cases  in  which  there  has  been 
a  great  loss  of  blood,  as  in  labor,  from  ulcer  of  the  stomach  and  from  wounds, 
but  this  usually  passes  off  very  quickly  after  the  hemorrhage  has  been 
checked,  ,ilt hough  a  more  or  less  severe  functional  disturbance  of  the  vision 
persists  in  many  cases,  which  is  due  to  a  partial  or  total  atro])hy  of  the  optic 
nerve. 

2.  Dilatations  of  the   Vessels. 

Just  as  a  straightening  accompanies  the  contraction  of  a  vessel,  so  a 
marked  tortuosity  is  commonly  associated  with  its  dilatation.  The  reflex  and 
the  color  of  the  blood  column  arc  also  accustomed  to  undergo  a  change,  the 
former  becoming  broader,  the  latter  darker  (see  Fig.  28)- 

Both  arteries  and  veins  may  be  dilated  at  the  same  time,  or  the  veins  alone 
may  be  affected.  A  dilatation  of  the  arteries  alone  is  not  likely  to  be  ob- 
served. If  the  dilatation  involves  both  the  arteries  and  the  veins  the  normal 
difference  between  their  transverse  diameters  is  maintained.  The  color  of  the 
fundus  is  not  changed  by  the  increased  fullness  of  the  vessels,  on  the  con- 
trary the  papilla  takes  on  a  livelier  color.  The  vessels  seem  to  be  increased 
in  number  because  the  smaller  ones,  which  are  usually  invisible,  come  into 
view.  At  the  same  time  it  must  be  remembered  that  under  certain  circum- 
stances the  number  may  seem  to  be  smaller  than  normal,  as  is  the  case  when 
there  is  coincidently  a  great  deal  of  oedema ;  for  example,  as  in  a  neuro- 
retinitis ;  the  smaller  and  deeper  branches  may  then  be  buried  completely 
in  the  oedema. 

(rt)   Uniform  Dilatation  of  the  Veins  and  Arteries 

is  met  with  as  a  local  symptom  of  general  plethora  in  fevers,  in  constitutional 
anomalies,  such  as  plethora,  or  the  apoplectic  habit,  and  in  overindulgence 
in  alcohol. 

Ocular  causes  to  which  it  may  be  due  are  the  sudden  relaxation  of  tension 
caused  by  operative  or  accidental  wounding  of  the  eyeball,  the  relief  from 
pressure,  as  in  operations  for  strabismus,  and  as  the  result  of  local  conges- 
tion produced  by  contusions,  by  a  downward  inclination  of  the  head,  by  too 
nnieh  light,  as  when  an  ophthalmoscopic  examination  is  prolonged  unduly, 
or  by  too  great  demands  having  been  made  on  the  acconmiodation.  It  is 
likewise  met  with  in  inflammation  of  both  the  anterior  and  posterior  segments 
of  the  eyeball.  In  this  respect  inflammation  of  the  optic  nerve  is  to  be 
mentioned  as  of  special  importance  (see  Optic  Neuritis,  page  72), 


101 

It  is  considered  by  sonic  authors  to  be  an  early  symptom  of  disease  of 
the  accessory  sinuses  which  may  be  tlie  very  first  to  appear.  It  is  also  to 
be  noticed  as  the  first  sign  of  a  cerebral  complication,  or  of  a  sinus  involve- 
ment, in  diseases  of  the  ear. 

In  Ieucoc3'thffmia  the  veins  are  apt  to  be  enormously  dilated,  while  the 
dilatation  of  the  arteries  is  only  moderate.  The  color  of  the  fundus  in 
these  cases  is  orange  red. 

(Ii)  Venous  Hyperaemia  with  the  Arteries  Normal  or  Con- 
tracted 

A'enous  hyperaemia  is  present  in  general  cyanosis  due  to  congenital,  rarely 
to  acquired,  heart  disease,  as  well  as  in  pneumonia,  emphysema,  and  poly- 
cyth.Tmia. 

It  is  due  to  local  causes: 

(a)  In  the  early  stage  of  plilebosclerosis ;  contraction  ensues  in  the  later 
stages. 

(/3)  In  acute  glaucoma  (Fig.  14,  pulsation  of  the  arteries,  varicosities 
of  the  veins),  and  in  secondary  glaucoma,  for  example,  from  an  intraocular 
tumor   (Fig.  50)- 

(y)  In  thrombosis  of  the  veins  (Figs.  27  and  28)1  the  most  essential 
and  most  prominent  symptom  in  which  is  the  enormous  hemorrhages. 

(S)  In  inflammation  of  the  head  of  the  optic  nerve  (albuminuric  choked 
disk)  and  of  the  retina  (Fig.  20,  page  79). 

(e)  In  compression  of  the  vessels,  either  directly  by  tumors  of  the  orbit, 
when  it  is  unilateral,  or  by  processes  that  increase  the  pressure  in  the  brain, 
when  it  is  bilateral  (Fig.  26). 

The  dilatation  of  the  veins  may  be  so  considerable  as  to  make  them 
appear  to  be  from  one  quarter  to  one  and  one  half  times  as  broad  as  normal. 

It  is  to  be  noticed  in  those  affections  which  are  accompanied  by  an 
oedema  of  the  retina  that  the  vessels  are  sometimes  so  embedded  in  the  oedema 
that  only  a  portion  of  their  transverse  sections  can  be  seen. 

3.  The  Differences  in  the  Proportional 
Sizes  of  the  Arteries  and  of  the 
Veins 

have  been  dealt  with  in  the  preceding  chapter,  and  tlie  only  thing  necessary 
is  to  call  attention  again  to  the  great  importance  of  this  point  in  the  differ- 
ential diagnosis  of  optic  neuritis  from  choked  disk  (page  79). 

4.  Unevennesses  of  Caliher 

in  the  course  of  individual  vessels  may  be  real  or  only  apparent. 

Real  inequalities  may  be  caused  by  uneven  scleroses  of  the  walls;  uneven 
in  both  the  sense  that  the  sclerosis  is  more  marked  in  some  places  than  in 
others,  and  the  sense  that  the  wall  of  the  vessel   is  thickened  more  on  one 


side  than  on  the  other,  so  tliut  the  Uinieii  is  displaced  from  tlie  center  of  the 
vessel,  or  is  made  oval.  As  scleroses  may  affect  tlie  wall  of  the  vessel  witiiout 
producing  any  opacltv  in  it,  and  as  the  breatitli  of  the  vessel  fluctuates 
within  fairl}'  wide  limits  under  physiological  conditions,  especial  weight  is  to 
be  placed  on  such  tmevennesses  of  cuUbcr  in  tlie  diagnosis  of  commencing 
sclerosis. 

Secondly,  the  inequality  of  caliber  may  lead  to  greater  or  less  pouching  i 
out  of  the  wall  of  the  vessel,  as  siiown  in  those  that  course  upward  in  Fig.  36, 
forming  aneurysms   of  the  arteries,  phlebectasiie  of  the  veins. 

Thrombi  may  readily  form  in  the  places  where  the  vessels  are  pouched  out. 

An  apparent  change  of  caliber  may  be  produced  by  the  embedding  of 
the  vessel  in  the  swollen  or  oedematous  retina  (see  Fig.  33),  or  in  the  tissue 
of  tlif  tumor  (  Fig.  50)- 

A  variation  in  caliber  may  also  be  simulated  by  the  presence  over  the 
vessel  of  such  tissues  as  medullated  nerve  fibers  (Fig.  9).  bands  of  connective 
tissue  (Fig.  37),  and  masses  of  exudate  (Fig.  38)-  Partial  interruptions 
in   tiirombosed  vessels  may   also   simulate  such   an   appearance. 

B.  The  Color  of  the  Vessels 

is  dependent  on  the  color  of  the  blood,  of  the  vessel  wall,  and  of  its  surround- 
ings. Ceteris  paribus  a  vessel  appears  to  be  darker  on  a  bright  than  on  a 
dark  background.  A  vessel  that  is  buried  very  deeply  In  the  retina  appears 
to  be  darker  than  one  that  is   superficial. 

The  vessels  are  pale  in  ana-mia,  chlorosis,  and,  to  a  very  marked  degree, 
in  leucocytha'mia.  In  the  latter  disease  the  color  of  the  veins  is  almost  the 
same  as  that  of  the  arteries,  so  that  the  former  can  be  distinguished  only  by 
their  greater  breadth  and  tortuosity. 

The  vessels  are  dark  in  thromboses  (Fig.  28),  and  in  venous  engorge- 
ments of  either  general  or  local  origin.  In  these  cases  the  ordinary  difference 
in  the  color  of  the  arteries  and  the  veins  is  particularly  distinct. 

In  cases  in  which  the  thrombosis  is  secondary,  for  example,  to  an  orbital 
cellulitis,  the  I'essels  are  very  dark  and  seem  to  be  almost  black. 

The  change  of  color  sometimes  affects  only  the  sides  of  the  vessels,  when 
it  produces  the  appearance  of  accompanying  stripes,  sometimes  its  entire 
breadth,  somctiincs  only   certain  portions  of  it. 

The  accompanying  stripes  may  be  due  to  various  causes.  Sometimes 
they  indicate  a  commencing  sclerosis;  in  these  cases  the  blood  colunui  is 
commonly  narrowed.  Although  they  are  to  be  seen  most  plainly  in  the  neigh- 
borhood of  the  papilla  they  are  to  be  found  there  least  often,  because  the 
smaller  vessels   are  usually  diseased  before  the  larger.^      In  most   cases  they 


^  The  sheathinps  of  the  vessel  confined  exclusively  to  the  vicinity  of  the  papilla 
are  usually  the  results  of  neuritic  changes  (see  under  Proliferation  of  glia). 


i();3 

spread  out  irregularly'  and  may  have  sharply  defined  edges,  or  may  blend 
gradually  with  the  transparent  portion  of  the  retina.  Sometimes  these  stripes 
can  be  seen  to  accompany  the  vessel  tiiroughout  its  entire  length.  In  very 
marked  cases  the  whole  vessel  may  finally  be  transformed   into  a  white  cord 

(Fig.  56). 

The  very  first  sign  of  such  a  disease  is  usually  a  broadening  of  the  central, 
reflex  light  streak,  after  which  the  changes  develop  that  have  been  described 
and  the  entire  vessel  becomes  gradually  transformed  into  a  slender,  white 
cord.  Generally  the  color  is  pure  white,  but  it  may  be  gray,  or  reddish  gray. 
The  pure  white  color  prevails  in  the  sheathings  to  be  described  below. 

Pathologicallv,  we  find  cellular  and  connective  tissue  proliferations  of 
the  intima  and  adventitia.  The  latter  may  lead  to  the  so-called  retinitis 
proliferans  (Fig.  37). 

The  sequeL-e  consist  of  diseases  of  the  retina  and  of  the  optic  nerve,  the 
same  as  in  simple  sclerosis,  and  the  same  etiological  factors  take  part.  As 
a  rule  the  two  forms  of  disease  cannot  be  recognized  as  distinct,  as  the  one 
passes  over  into  the  other ;  they  are  spoken  of  here  under  two  heads  simply 
for  the  sake  of  clearness. 

Secondly,  the  accompanying  stripes  may  be  caused  by  a  proUferaiion  of 
the  gVui,  (IS  the  consequence  of  an  optic  neuritis  (Figs.  12  and  21).  It  has 
already  been  mentioned  that  the  indistinct  margins  and  the  white  color  of 
the  papilla  in  an  atrophy  that  results  from  an  optic  neuritis  are  caused  by 
a  proliferation  of  the  interstitial  glia  tissue  and,  in  harmony  with  such  an 
etiology,  this  sort  of  sheathing  is  found  only  on  tlie  optic  nei-ve,  or  in  its 
immediate  vicinity,  or  at  least  it  is  most  pronounced  in  this  locality.  The 
demonstration  of  such  a  change  is  therefore  valuable  evidence  in  favor  of 
the  neuritic  nature  of  an  atrophy  of  the  optic  nerve.  The  color  is  commonly 
a  pure  white,  in  which  it  varies  from  other  forms  of  sheathing. 

A  third  form  is  shown  in  Fig.  42.  This  is  the  one  that  is  met  with  in 
those  cases  in  which  an  acute  sheathing  of  the  retinal  vessels  appears  simul- 
taneously with  signs  of  retinitis ;  it  can  be  explained  only  as  a  filling  of  the 
lymph  spaces  of  the  adventitia  with  white  blood  corpuscles. 

The  bright  bands  along  the  upper  vessels  in  Fig.  33  have  to  be  explained 
in  a  similar  manner,  except  that  here  the  fluid  has  already  left  the  sheaths 
of  the  vessels. 

The  white  deposits  of  lime,  and  other  concrements,  that  occur  here  and 
there,  need  only  to  be  mentioned. 

The  complete  interi-uption  of  a  vessel  with  the  signs  of  a  sudden  occlusion 
(see  Fig.  45)   indicates  the  presence  of  an  embolus,  or  a  thrombus,  within  it. 

Sometimes  the  accompanying  stripes  are  only  simulated  by  the  reflection 
of  light  along  the  vessels.  This  sort  of  reflection  is  seen  very  often  (see 
page  26),  especially  in  young  persons  in  whom  the  fundus  is  dark.  They 
can  be  recognized  from  the  fact  that  they  change  as  the  mirror  is  rotated. 
Such  reflections  are  shown  in  Figs.  2  and  30- 


104. 

C.  Changes  in  the  Number  of  the  Vessels 

The  numbiT  of  vessels  may  be  diminislied  or  increased. 

A  diminution  is  met  with  in  marked  sclerosis  (Fig.  56))  as  well  as  in 
injuries  and  diseases  of  tlie  retina,  especially  those  that  are  associated  with 
a  development  of  connective  tissue  (Fig.  36). 

An  .apparent  diminution,  due  to  some  being  rendered  invisible,  is  to  be 
observed  when  tiie  optic  nerve  is  suddenly  severed  througli  the  portion  that 
contains  the  vessels,  wlien  arteries  are  occluded  (Figs.  44  and  45),  and 
when  great  u-dema  is  present,  as  well  as  in  cases  of  tumor  and  of  detachment 
of  the  retina. 

A  smaller  iuiihIht  of  vessels  than  lun-mal  may  be  present  congenitally, 
but  such  a  condition  is  connnonly  associated  with  other  anomalies  in  the 
fundus. 

An  increase  in  the  number  of  vessels  may  likewise  be  real  or  only  apparent. 

A  true  increase  is  caused  by  a  new  formation  of  large  veins,  or  of  loops 
of  small  vessels.  These  are  to  be  observed  when  gross  circulatory  disturb- 
ances are  present  in  the  eye,  as  in  comjiression,  or  partial  obliteration  of  the 
central  vein,  i.e.,  in  such  conditions  as  favor  the  origin  of  a  choked  disk,  as 
well  as  in  glaucoma  and  after  thromboses  of  the  veins.  As  a  rule  the  newly 
formed  veins  are  the  so-called  opticociliary  veins  (see  page  23),  yet  some 
can  be  seen  in  the  retina  alone. 

The  loops  of  small  vessels  are  ])articularly  connnon  in  choked  disk  (Fig. 
25)  ;  they  are  to  be  seen  more  rarely  in  diseases  of  the  retina  which  are 
associated  with  a  proliferation  of  connective  tissue.  They  have  also  been 
observed  after  injuries  to  the  optic  nerve  and  retina.  In  most  cases  the^' 
lie  on  the  papilla  itself. 

An  apparent  increase  is  seen  when  vessels  that  are  otherwis(>  invisible 
come  into  view  as  the  result  of  distention,  or  of  the  fact  that  their  walls  have 
been  made  visible.  Such  an  apparent  increase  is  seen  in  commencing  sclerosis 
of  the  vessels,  in  vascular  engorgement  from  compression  of  the  veins  or 
glaucoma,  in  leucocytha^mia,  and  in  detachment  of  the  retina.  When  the 
central  artery  is  occluded  the  veins  about  the  macula,  which  are  otherwise 
scarcely  visible,  come  plainly  into  view  (Fig.  45). 

A  surplus  of  vessels  may  be  congenital,  yet  in  most  cases  there  is  no 
oversupply,  but  the  deceptive  appearance  is  caused  by  the  fact  that  the 
vessels  which  usually  divide  on  the  papilla,  or  after  they  have  left  it,  have 
divided  before  they  leave  the  hilus  (see  page  22). 

The  presence  of  opticociliary,  or  retinociliary,  vessels  can  scarcely  be 
regarded  as  pathological ;  they  arc  rather  to  be  considered  to  be  physiological 
variations  (see  page  23). 

The  vessels  which  are  to  be  observed  in  connection  with  other  disturbances 
in  the  fundus,  for  example,  with  a  coloboma  of  the  chorioid.  are  rarely  of  a 
retinal,  but  usually  of  a  chorioidal  or  scleral  nature  (Figs.  84  and  85)- 


105 

The  division  of  tlie  retinal  vessels  may  present  certain  deviations  from 
the  normal.  Thus  it  can  be  seen  in  many  cases  that  some  parts  of  the  fundus 
usually  provided  with  vessels  are  destitute  of  them,  while  other  parts  on  the 
contrary  show  a  superabundance.  This  condition  may  be  either  congenital, 
or  be  brought  about  by  certain  pathological  processes,  for  example,  by 
connective  tissue  formations  which  jiull  the  retina  in  one  direction  or  another. 
The  subdivision  may  also  deviate  froiii  the  normal  as  the  result  of  the  destruc- 
tion, or  the  new   formation   of  vessels. 

D.  The  Course  of  the   Individual  Vessel 

shows  some  typical  peculiarities.  The  vessels  in  myopia,  especialiv  when  it 
is  of  high  degree,  seem  to  be  nmch  stretched,  or  drawn  out  (Fig.  72).  On 
the  contrary  the  course  of  the  vessel  is  very  crooked  in  hypermetropia,  so 
much  so  that  we  sometimes  speak  of  a  tortuositas  vasorum. 

The  disproportion  between  the  size  of  the  eyeball  and  the  surface  of  the 
retina  is  the  cause  of  this  peculiar  behavior,  but  in  other  cases  the  size  of 
the  caliber,  i.e.,  tlie  fullness  of  the  vessel,  is  tlie  actuating  cause,  so  that  a 
marked  tortuosity  is  associated  with  a  distention  of  a  vessel,  and  a  stretciving, 
due  to  a  simultaneous  tension  in  its  long  axis,  with  its  contraction. 

The  careful  study  of  the  course  of  the  retinal  vessels  is  of  extremely  great 
importance  in  the  determination  of  differences  of  level  within  tiie  eve.  As 
we  look  into  the  eye  of  a  patient  witli  only  one  eve  we  cannot  make  use  of 
our  stereoscopic  perception  of  depth,  as  tliis  is  dependent  on  binocular  vision. 
We  can  perceive  differences  of  level  only  by  the  aid  of  secondary  means, 
among  which  the  course  of  the  vessels  is  a  very  efficient  one.  A  number  of 
fresh  tubercles  are  shown  along  the  course  of  the  inferior  temporal  vein  in 
Fig.  78;  the  wavy  course  of  the  vessel  enables  us  to  perceive  wiiere  the 
elevations  are.  In  Fig.  47  is  pictured  a  detachment  of  the  retina:  tlie  folds 
of  the  detached  retina  may  be  recognized  from  the  wavv  courses  of  the 
retinal  vessels.  We  judge  in  like  manner  concerning  the  conditions  of  level 
in  a  choked  disk,  in  a  commencing  tumor,  and  in  a  proliferation  of  connective 
tissue  (Fig.  23). 

How   important    the    observation    of   the    course    of   the    vessels   is    in    the 

diagnosis  of  glaucoma  has  already  been  pointed  out  on  page  56. 

■ 

E.  The  Reflex 

of  the  retinal  vessels  comes  from  those  places  that  are  vertical  to  the  line 
of  direction  of  the  observing  eye.  It  is  strongest  and  liroadest  on  the  large 
vessels,  yet  it  is  visible,  especially  in  young  persons,  on  the  minute  branches, 
although  it  is  weak  and  narrow ;  it  is  absent,  however,  even  on  vessels  of 
medium  size  in  senile  ej'es. 

On  the  arteries  it  is  generally  brighter,  more  intense,  narrower,  and  more 


lOf) 

sharply   defined    than    on    the    veins,   yet    the    reverse   condition    is    sometimes 
met  with. 

The  reflex  may  undergo  great  individual  iliutiiat  ions,  uiuln-  physiological 
conditions,  witii  i-eganl  to  intensitv,  unitoiinil  \ ,  l)r(adtli,  margins,  color,  aTul 
its  comparative  condition  on  the  arteries  and  on  the  veins,  whih'  it  cainiot 
be  determined  in  the  individual  case  what  has  brought  about  the  change. 
Still  a  few  important  points  may  be  noticed. 

The  reflex  is  almost  as  useful  as  tlie  wavy  course  of  the  vessels  m  the 
determination  of  differences  of  level,  for  at  any  elevation,  no  mattei-  how 
slight,  of  the  vessel  above  the  level  of  the  retina,  tiie  reflex  disappears  at  the 
place  wliere  tlie  bend  takes  place  (Figs.  23,  24)- 

The  reflex  from  the  vessels  is  totally  absent  in  detachment  of  the  retina 
(Fig.  46)-  The  slightest  extravasation  or  (wlema  in  the  neighborhood  of 
the  vessel   causes  its  reflex  to  disappear. 

Under  certain  pathological  conditions  tlir  coloi-  of  the  arteries  approaches 
that  of  the  veins,  or  the  reverse,  and  tlun  thi'  reflexes  will  be  similar  to 
each  other. 

The  more  superficial  the  situation  of  the  vessel,  tlie  more  distinct  and 
sharply  defined  is  tlie  reflex;  the  dee])er  the  vessel,  tlie  less  clear  its  light 
streak  becomes. 

When  the  blood  pressure  is  decreased  tlie  reflex  becomes  broader,  when 
increased  it  becomes  narrower. 

In  the  beginning  of  an  arteriosclerosis  the  particularly  intense,  strikingly 
bright  reflexes  on  certain  parts  of  the  vessel  are  the  only  signs  of  the  disease. 
In  the  later  course  of  the  sclerosis,  as  atrophy  sets  in,  they  gradually  dis- 
appear. 

There  is  no  agreement  among  authors  as  to  the  cause  and  place  of  origin 
of  this  reflex.  Originally  it  was  tliougiit  that  the  surface  of  the  vessel  itself 
reflected  the  light,  hut  this  idea  has  been  abandoned,  as  tiie  result  of  experi- 
ments and  discussion.  The  theory  that  meets  with  the  most  favor  is  the  one 
advanced  by  Dimmer,  that  the  reflex  comes  from  the  surface  of  the  column 
of  blood  in  the  veins,  and  from  the  place  of  the  axial  current  in  the  arteries. 
Yet  objections  can  be  raised  against  this  theory ;  Elschnig,  for  example,  has 
shown  that  the  reflex  remains  visible  on  the  arteries  after  the  circulation 
has  ceased. 

F.  Phenomena  of  Pulsation 

Venous  and  Artrrwl  Pulse. 

Pulsation  of  the  retinal  veins  is  a  normal  phenomenon  which  is  to  be  seen 
most  distinctly  in  the  large  vessels  at  the  iiiius,  at  the  place  where  they 
descend  into  the  excavation.  The  veins  best  suited  for  observation  are  the 
large  ones  that  end  in  a  point  or  beak  at  the  hilus.  The  blood  column  seems 
to  be  driven  backward,  toward  the  periphery  at  each  stroke. 

Two  different  pulsatory  phenomena  are  included  under  the  term  pulsation 


107 

o/  the  refined  arteries:  1,  the  coniprussion  pulse,  wliicli  manifests  itself  in  a 
greater  and  less  fullness  during  the  systole  and  the  diastole;  2,  rhythmic 
fluctuations  of  caliber. 

The  peculiar  behavior  of  pulsation  in  the  eye,  that  a  venous  pulse  is  nor- 
mal and  that  an  arterial  pulse  is  not,  is  explained  by  the  fact  that  the  vessels 
are  subjected  to  an  external  pressure,  the  so-called  intraocular  tension,  while 
the  vessels  in  other  parts  of  the  body  are  not.  The  ])ulsation  of  the  arteries 
is  prevented  by  this,  and  the  veins,  which  have  walls  that  affortl  little  resist- 
ance, are  compressed  by  it  while  they  are  less  filled  during  the  diastole.  It 
is  only  when  the  relative  conditions  of  pressure  are  changed,  for  example, 
wlien  the  intraoruhir  tension  is  increased,  or  when  the  intra-arterial  pressure 
rises  abnormally  high,  or  falls  abnormally  low,  that  an  arterial  pulse  can 
be  observed.  The  elevation  of  the  intraocular  tension  can  also  be  brought 
about  by  compression  of  the  eyeball.  If  pressure  is  made  with  the  finger 
upon  the  eyeball  during  an  ophthalmoscopic  examination,  a  venous  pulse  is 
seen  at  first  and  then,  as  the  pressure  is  increased,  an  arterial  pulse;  finally, 
if  the  pressure  is  sufficiently  forceful,  the  retinal  vessels  become  completely 
empty  of  blood. 

The  venous  pulse  is  met  with  frequently  in  normal  eyes,  but  usually  only 
in  young  people.  In  old  age  a  distinct  venous  pulse  is  indicative  of  a  com- 
mencing phlebosclerosis.  Absence  of  the  pulse  when  the  eyeball  is  gently 
pressed  by  the  finger  is  a  symptom  of  thrombosis  of  the  central  vein. 

An  arterial  pulse  is  always  to  be  regarded  as  pathological.  It  indicates 
either  an  abnormally  high  blood  pressure,  an  abnormally  high  pressure  wave 
in  the  ai-terial  svstem,  as  in  cardiac  hypertrophy,  aortic  insufficiency,  aneu- 
rysm of  the  aorta  or  carotid,  and  exophthalmic  goitre,  or  an  abnormally  low 
blood  pressure,  as  after  great  loss  of  blood  and  in  syncope,  or,  finally,  an 
increased  intraocular  tension,  as  in  glaucoma.  Absence  of  the  aortic  pulse 
when  the  eyeball  is  pressed  upon  by  the  finger  has  been  observed  in  occlusion 
of  the  central  artery  of  the  retina. 


Retina 


Retina 

A.  Preliminary  Remarks  on  the  Anatomy 

In  an  eye  that  has  been  cut  open  the  retina  presents  itself  as  a  gray, 
cloudy  membrane  about  Vs  mm  thick,  which  separates  easily  from  the  pig- 
ment layer  and  is  closely  connected  with  the  subjacent  tissue  in  only  two 
places,^  the  entrance  of  the  optic  nerve  and  the  foyea  centralis.  When  the 
retina  is  seized  with  forceps  and  removed  from  the  eye  the  pigment  layer 
remains  in  close  connection  witii  the  chorioid.  Nevertheless  the  layer  of 
pigment  epithelium  belongs  embryologically  and  physiologically  to  the  retina, 
it  is  the  outer  layer  of  the  secondary  optic  vesicle.  The  center  of  the  retina 
appears  yellowish,  the  macula  lutea,  with  a  dark  brown  point,  the  fovea 
centralis. 

In  the  living,  normal  eye  the  retina  is  perfectly  clear  and  transparent, 
so  that  its  presence  can  be  perceived  only  by  means  of  the  vessels  that  course 
in  it.-  The  color  of  the  fundus  is  therefore  not  influenced  by  that  of  the 
retina  itself,  but  is  due  essentially  to  the  greater  or  less  abundance  of  the 
pigment  contained  in  the  pigment  layer  and  in  the  chorioid ;  the  color 
of  the  chorioidal  vessels  plays  a  subordinate  part.  The  peculiar  color  of  the 
macula  is  suppressed  by  tliat  of  the  subjacent  tissue;  it  appears  only  a  little 
darker  than  its  surroundings.  Its  center,  the  fovea  centralis,  is  still  darker, 
because  the  retina  is  very  thin  at  that  point  and  consequently  the  chorioid 
and  pigment  epithelium  show  through  with  special  clearness.  The  contrast 
with  its  surroundings  becomes  particularly  marked  wlien  the  retina  in  the 
vicinity  of  the  macula  is  cloudy,  as  in  occlusion  of  the  central  artery  (see 
Fig.  44). 

The  layers  of  the  retina  are  known  as  the  outer  and  the  inner,  ac- 
cording to  their  positions  relative  to  the  contents  of  the  eye.  Those  lying 
nearest  to  the  vitreous  are  called  the  inner  layers,  those  more  distant  the 
outer.  The  outer  layers,  i.e.,  the  layer  of  rods  and  cones,  the  outer  granular 
layer,  and  the  membrana  limitans,  which  lies  between  them,  form  what  is 
known  as  the  layer  of  sensory  epithelium,  while  the  others,  which  occupy  the 
inner  portion  of  the  retina,  are  grouped  together  as  the  cerebral  layer. 

This  is  a  division  which  is  not  simply  anatomical,  but  is  of  great  clinical 
and  diagnostic  importance,  as  the  two  layers  receive  nutrition  from  different 
sets  of  vessels. 

•  The  retina  is  also  attached  to  the  chorioid  at  the  era  serrata. — F. 
-A  delicate  striation,  radiating  from  the  papilla,  is  visible  in  many  normal  eyes; 
this  is  to  be  referred  to  the  color  of  the  retina  itself. 

m 


\V2 

A  full  and  precise  dcscri})Hon  of  the  anatomy  would  nquin-  too  nuich 
space,  so  onlv  thoso  points  will  l)i'  iiuntioned  which  ;n\-  of  c^)n^i(l^■^;d)lc  clin- 
ical importance.  Thr  layers  of  nerve  fibers  consist  of  hundles  of  naked  iiei'vc 
fibers  which  lace,  as  it  were,  into  a  plexus.  It  is  only  in  exceptional  cases  tliat 
the}'^  have  medullary  sheaths  and  form  a  white  s[)ot  (meduUated  nerve  fibers, 
sec  Fig.  9).      The  til)ers  radiate   from   the  papilla,  with   the  exception   of  those 


Layer   of    pigment 
epithelium 

Layer  of  rods  and 
cones 

Membrana  Hmitans  (. 
externa  I 

Outer  granular 
layer 


Outer  molecular 
layer 


Inner  granular 
layer 


Inner  molecular 

layer 


Layer  of  ganglion 
cells 

Layer  of  optic 
nerve  fibers 


^B^S^PS^QI 


j  Layer    of   pigment 
I      epithelium 

j  Layer  of  rods  and 
I      cones 

3  Layer  of  granules 
/      and  visual  cells 

f        ^ 

J  Outer  plexiform 
^         (      layer 

■  '^    \  Layer  of  horizontal 
w         \      cells 

J  Layer  of  bipolar 
I      cells 

_^       S  Layer  of  amacrine 
3-    \      cells 

nner  plexiform 
layer 

I  Layer  of  ganglion 

\      cells 

J  Layer  of  optic 
[      nerve  fibers 


Fig.  Q. 
Anatomy  of  the  Retina,  after  Oreeff. 


cnniinw  from  its  temporal  side,  wliicli  circle  in  a  great  arch  about  the  macula. 
The  macula  itself  is  supplied  by  particularly  fine  fibers  which  run  directly  to 
it  from  the  temporal  margin  of  the  paj)illa  (the  papillomaculai-  i)un(lle,  see 
pages  1(5  and  .58).  The  construction  of  the  retina  undergoes  changes  l)oth 
at  the  macula  and  at  the  periphery,  which  are  of  clinical  interest. 

The  macula  is  situated  about  ll^  papillary  diameters  (i  mm)  outward 
and  a  little  downward  from  the  entrance  of  the  optic  nerve,  in  the  inverted 
image  of  course  inward  and  upward,  is  usually  transversely  oval,  less  often 
rounil,  and  measures  in  its  horizontal  diameter  l.T  to  2  mm.  Its  margins 
are  a  little  raised,  and  in  its  center  is  a  depression  with  level  margins,  the 
fovea  centralis.  The  number  of  the  cones  increases  toward  the  fovea  at  the 
expense  of  the  rods. 

To  give  a  verv  rough  idea  of  the  anatomy  it  may  be  imagined  that  the 
cone  fibers,  and  with  them  their  connections,  are  combed  apart,  or  parteil 
like  hair,  at  the  fovea,  so  as  to  lav  bare  the  cones  at  the  bottom  of  the  part. 

The  peripheral  portions.  While  the  number  of  the  cones  increases 
as  the  macula  is  ai)])r(i.ulu(l,  it  decreases  toward  the  periphery,  where  the 
rods  preponderate  in  mnnher  considerably.  IJoth  cease  at  the  ora  serrata. 
The  other  layers  also  blend  at  this  place  until  only  a  single  layer  of  cylin- 


11  !3 

driccil  cells  is  left,  hcnuatii  which  lies  the  pigment  layer,  with  whicli  it   forms 
an  intimate  connection  as  it  passes  over  to  the  iris. 

The  nutrition  of  the  retina  is  derived  from  two  sources:  1,  the  central 
artery,  2,  tlie  vessels  of  the  chorioid.  The  former  supplies  the  cerebral  layer, 
the  latter  the  layer  of  nerve  and  pigment  epithelium. 

1.  The  principal  branches  of  the  central  artcr/j  of  the  retina  run  close 
to  the  inner  surface  of  the  layer  of  nerve  fibers,  or  project  above  this  into 
the  vitreous,  but  are  always  covered  by  a  few  bundles  of  nerve  fibers. 

2.  The  layer  of  nerve  epithelium  is  entirely  without  blood  vessels  and  re- 
ceives its  nourishment  by  diffusion  from  the  capillary  network  of  the  chorioid ; 
the  fovea  centralis  is  likewise  nonvascular,  the  fine  retinal  vessels  end  in  a 
circle  of  capillary  loops  on  its  margin. 

Physiology.  The  percipient  organs  of  the  retina  are  the  rods  and  cones, 
but  these  lie  in  its  outer  layer,  toward  the  sclera.  This  gives  the  peculiar 
condition  that  the  rays  of  light  must  first  pass  through  the  entire  thickness 
of  the  retina  in  order  to  reach  the  organs  of  perception.  Hence  the  necessity 
of  the  perfect  transparency  of  tlie  retina,  and  of  the  absence  of  vessels  in  the 
region  of  the  macula. 


& 


B.    General  Diagnosis 

Ophthalmoscopic  Differentiation   of  Di.seascii  of  the  Inner  and  Outer  Layers 
of  the  Retina   and  of  the  Chorioid 

As  the  pigment  epithelium  as  well  as  the  neuroepithelium  receives  its  nu- 
trition from  the  choriocapillaris  of  the  chorioid,  the  appearance  of  pigment 
changes  is  the  characteristic  symptom  of  the  ophthalmoscopic  picture  pro- 
duced by  a  disturbance  in  this  vascular  region.  On  account  of  the  simul- 
taneous involvement  of  the  retina  and  the  chorioid  we  do  not  speak  in  these 
cases  of  a  retinitis,  but  of  a  chorioretinitis.  Although  in  rare  cases  a  pig- 
mentation of  the  retina  may  take  place  as  the  result  of  a  retinal  hemorrhage, 
yet  in  the  majority  the  following  statement  is  correct: 

The  appearance  of  pigment  stains,  and  of  abnormal  accumuhition>t  of  pig- 
ment, in  the  retina  indicates  a  disease  of  its  outer  lai/ers.  or  of  the  chorioid.  a 
chorioretinitis:  diseases  of  the  retina  uithout  invohement  of  the  pigment  are, 
on  the  contrary,  of  its  inner  layers. 

The  Position  of  tlie  Cliaiiifcs  in  tlir  lleliiin. 

i.e.,  the  depth  at  which  they  lie,  can  be  determined  ophthalmoscopically : 

1.  From  their  relations  to  the  retinal  vessels.  If  the  latter  pass  over  the 
former  the  changes  are  deeper  than  the  vessels  and  therefore  ai'e  in  the  deeper 
laj'ers  of  the  retina  (Fig.  31  )•  If.  on  the  contrary,  the  vessels  are  partly 
or  wholly  covered,  the  changes  lie  in  the  superficial  layers  (Fig.  33).  Should 
the  vessels  be  completely  hidden,  as  by  a  hemorrhage,  the  change  must  be 
upon  the  retina,  and  the  hemorrhage,  in  the  example  cited,  is  called  preretinal. 


114 

2.  From  their  form  and  arrangement.  Sti'iatid  putclies  or  liemorrhaf^es 
(Fig.  32),  especially  such  as  extend  in  the  foi-iii  of  rays  from  the  papilla, 
or  accompany  the  larger  vessels  (see  Fig.  28),  He  in  the  most  superficial 
layers  and  follow  in  them  the  course  of  the  nerve  fibers.  When  tliey  are 
irrefrular,  or  inclined  to  be  round,  they  usually  lie  in  the  deeper  layers  (Fig. 
35)-  An  exception  to  this  rule  is  formed  by  the  stellate  patches  in  the  macula 
seen  in  albuminuric  retinitis  (Fig.  34),  which  lie,  in  spite  of  their  i-adiation, 
in  the  deeper  layers  of  the  retina. 

3.  From  the  presence  or  absence  of  anomalies  of  pigment.  The  presence 
of  these  shows  that  the  changes  lie,  in  part  at  least,  in  the  deepest  layers  of 
the  retina. 

Betiititis. 

The  name  retinitis  is  used  to  indicate  things  with  which  infiammation  has 
nothing  to  do.  A  reform  of  ophthalmological  nomenclature  is  greatly  needed 
here.  As  soon  as  hemorrhages,  or  bright  spots,  or  dark  spots  are  visible  in 
the  fundus,  the  patient  is  said  to  have  retinitis,  no  matter  whether  they  are 
foci  of  inflammation,  products  of  dei)-ener;ition,  or  the  results  jjroduced  by 
altered  vessels.  To  be  sure,  inflannnation  and  detruneration  can  scarcely  bo 
discriminated  in  the  ophthalmoscopic  picture,  and  the  pathological  condi- 
tions that  have  been  found  in  other  similar  cases  must  be  taken  into  account 
in  order  to  be  able  to  determine  the  disease  in  any  particular  case.  Usually 
that  which  is  called  retinitis,  and  is  manifested  in  the  form  of  diffuse,  or  cir- 
cumscribed bright  spots,  or  of  hemorrhages,  is  the  result  of  diseases  of  the 
vessels. 

The  extremely  sensitive  tissue  of  the  retina,  with  its  very  small  capillaries, 
reacts  with  great  ease  to  any  disturbance  of  circulation,  and  likewise  any 
change  in  the  composition  of  the  blood  or  tissue  juice  leaves  its  trace  in  the 
retina.  Often  the  very  first  signs  of  a  general  disease  are  made  visible  in  the 
retina  because  it  is  so  very  sensitive. 

Unfortunately  the  manifestations  in  the  eye  of  the  various  constitutional 
diseases  are  remarkably  alike,  so  that  it  is  only  in  rare  cases  that  the  exact 
etiological  diagnosis  can  be  made  from  the  ophthalmoscopic  picture  alone,  it 
usually  has  to  be  learned  from  the  results  of  a  general  examination.  Even 
though  it  is  not  always  possible  to  make  the  etiological  diagnosis  from 
the  ophthalmoscopic  examination,  yet  this  much  can  be  learnid.  tliiit  a  (jrii- 
crtil  disease  is  present  in  oil  cases  in  xehicli  fresh  changes  arc  found  in  the 
form  of  white  or  black  spots,  opacities,  or  hemorrhages.  In  such  a  case  it  is 
our  imperative  duty  to  submit  the  body  to  a  very  thorough  examination,  pay- 
ing particular  attention  to  the  urine. 

Are  Alterations  in  the  Pigment  Epithelium  Present  or  Not? 

The  inner  layers  of  the  retina  are  nourished  by  the  central  artery,  while 
the  outer,  together  with  the  pigment  epithelium,  derive  their  nutriment   from 


115 

the  chorioid,  us  has  been  already  pointed  out.  Disturbances  in  the  central 
artery  of  the  retina  therefore  are  made  manifest  by  chanjfes  in  the  inner 
layers,  those  in  the  chorioid  by  changes  in  the  outer  layers  and  particularly 
in  tlie  pigment  epitlielium.  This  is  the  reason  why  the  question,  whether 
alterations  are  present  or  not  in  the  pigment  epithelium,  is  of  such  great  im- 
portance, for  the  answer  to  this  question  is  decisive  with  regard  to  the  seat 
of  the  disease  and  the  vascular  system  that  is  affected. 

The  alteration  of  the  pigment  epithelium  may  manifest  itself  in  two  ways, 
either  as  a  depigmentation,  i.e.,  an  atrophy  of  tlie  j)igiiient  layer,  or  as  an 
abnormal  accumulation  of  pigment.  Depigmentation  lays  bare  the  tissue  of 
the  chorioid  and  allows  the  chorioidal  vessels,  which  are  more  or  less  changed 
in  such  cases,  to  be  seen,  when  the  sclera  itself  is  not  laid  bare  by  the  sim- 
ultaneous atrophy  of  the  chorioid.  This  gives  rise  to  white  spots,  which  need 
to  be  differentiated  from  the  white  spots  of  the  retina.  For  the  differential 
diagnosis  see  page  125. 

C.  Special  Diagnosis 

We  have  made  quite  a  digression  into  a  rather  theoretical  field  and  will 
now  return  to  the  practical  diagnosis. 

We  liavc  studied  the  papilla  and  its  vicinity  with  tlie  greatest  care,  wo 
have  observed  the  retinal  vessels  from  the  various  points  of  view,  and  now  we 
turn  to  the  diagnosis  of  the  special  diseases  of  the  retina.  We  will  be  guided 
first  by  the  question. 

Are  Pigment  Changes  Present  or  \ot? 
and  will  deal  first  with 

Retinal  Lesions  Which  Exhibit   No  Alterations  in  the  Pigment 

Epithelium 

(Diseases  of  the  inner  la^'ers.) 

These  are  mainly 

Hemorrhages, 
White  Spots,  and 
Diffuse  Opacities. 

These  will  guide  us  further.  Naturally  all  three  disturbances  niaA*  be 
present  at  the  same  time.  Hemorrhages  and  wliite  spots  occur  together  very 
often.  So,  too,  are  diseases  of  the  optic  nerve  often  combined  with  these 
changes  in  the  retina.  Hence  we  will  make  the  following  subdivisions  in  order 
to  proceed  in  the  differential  diagnosis: 


116 

/.  Hemorrhages: 

(«)  As  the  onl/j,  or  the  most  importiint  change  in   the  retinii.  perhaps 
in  combination  teith  changes  in   the   retinal  vessels: 

{!))    in  connection  :dth  diseases  of   the  optic  ner-ee  and  its  r^icinil//. 

II.  \\  liite  spats  uitli  or  uithout  lictnorrliat/es  or  diseases  of  the  oiitic 
nerve. 

III.  Diffuse  opacities. 

I.    HEMORRHAGES 

(a)   Hemorrhages  as  the  Only,  or  the  Most  Important  Change 

in  the  Retina. 

Aftor  wliat  has  heuii  said  it  may  scxiii  uiimctssarv  to  call  attention  to  thu 
significance  of  hcniorrhaircs  in  the  fundus,  hut  this  definite  statement  may  be 
repeated  on  account  of  tlic  importance  of  the  subject:  117((7(  injuries,  high 
myopia,  and  glaucoma  can  he  excluded  hemorrhages  are  alzca//s  signs  of  a 
general  disease.  They  form  a  siuiial  of  warniri"-;  there  is  somethiiiii-  out  of 
order  in  the  organism  ;  make  a  general  examination.  Even  when  the  hemor- 
rhage is  as  sliglit  as  that  to  be  seen  in  Fig.  20.  it  may  and  must  be  made  the 
starting-point  of  the  diagnosis  of  a  serious  dise.ise. 

After  hemorrJiage.s  have  been  found  special  questions  arise  cojtcerri' 
ing  their  size,  abundance,  and  position. 

Hemori-hagcs  may  be  of  the  most  varied  e.xtent ;  sometimes  we  find  little, 
circumscrii)ed  })atches,  which  can  be  seen  only  after  a  very  careful  search  with 
the  pupil  dilated,  and  in  the  upright  image  alone.  The  only  advice  that  can 
be  given  the  physician — and  this  implies  no  question  as  to  his  skill — is  to 
dilate  the  pupils  in  a  doubtful  case  in  order  to  be  able  to  make  a  more  accu- 
rate examination.  The  only  precautions  to  be  observed  are  those  given  on 
page  11. 

On  the  other  hand,  the  hemorrhages  may  be  so  massive  as  to  form  the 
most  prominent  feature  of  the  ophthalmoscopic  picture,  as  to  cover  every 
detail,  and  to  make  the  fundus  look  like  a  single  lake  of  blood  (see  Fig.  27). 
The  number  also  of  the  hemorrhages  may  vary  extremely. 

As  regards  the  depth  at  which  they  are  situated  it  has  already  been  said 
that  fine,  striated  hemorrhages  which  radiate  from  the  papilla  lie  quite  super- 
ficially in  the  layer  of  nerve  fibers,  while  roundish,  or  lumpy  ones  are  to  be 
sought  in  the  middle  or  deep  layers.  Hemorrhages  that  cover  the  retinal  ves- 
sels lie  in  front  of  the  retina  and  are  called  preretinal ;  they  are  usually  round, 
or  oval,  in  form,  and  are  found  for  the  most  part  in  the  region  of  the  macula. 

Topograj)hically  the  following  points  have  to  i)e  noted:  the  position  of  the 
hemorrhages  relative  to  the  papilla,  to  the  macula,  and  to  the  large  vessels, 
whether  they  are  diffusely  distributed,  and  whether  they  are  in  the  vitreous. 


117 

Small  hemorrliagcs  come  from  tlie  capillaries,  large  ones  fioiii  tlic  larger 
vessels.  It  is  often  impossible  to  differentiate  between  a  venous  and  an  arterial 
hemorrliaee,  and  the  differentiation  is  of  little  use.  When  ditt'ei-eiues  in  color 
are  to  be  seen  they  are  to  be  ascribed  to  the  different  ages  of  the  iieniori-hages, 
as  fresh  ones  are  of  a  bright,  blood  red,  while  old  ones  are  of  a  dark,  l)rown 
red. 

Note.  The  absorption  of  hemorrhages  takes  place  pretty  slowly  as  a 
rule.  The  spots  gradually  become  darker,  until  they  finally  disappear  witiiout 
leaving  any  traces,  or  tiiey  become  transformed  Into  wiiite  sjiots,  wliicli  in 
turn  become  invisible;  it  is  only  in  rare  cases  that  masses  of  connective  tissue 
and  pigment  remain  as  traces  of  a  hemorrhage.  On  the  other  hand,  hemor- 
rhages may  last  for  months.  The  impairment  of  the  functions  of  the  retina 
depends  on  the  situation,  the  force  exerted  at  the  time  when  tiiey  occurred, 
and  their  size.  An  attack  of  glaucoma  may  be  mentioned  as  one  of  the  pos- 
sible consequences  of  a  severe  intraocular  hemorrliage,  but,  inversely,  glau- 
coma may  also  be  the  cause  of  iiemorrhage   (see  page  120). 


Is  a  Differential  Diagnosis  Possible,  Based  on  These  Findings? 

It  is  in  many  cases : 

1.  From  the  extent.  If  we  find  as  extensive  a  hemorrhage  as  that  shown 
in  Fig.  27  we  can  confidently  base  upon  it  the  diagnosis  of  thrombosis  of 
the  main  trunk  of  the  central  vein.  This  clinical  picture  was  named 
by  V.  Michel  apoplexia  sanguinea  and  compared  by  iiim  with  corresponding 
hemorrhages  in  the  brain.  When  we  study  the  details  of  the  picture  we  are 
struck  by  the  fact  that  we  cannot  actually  see  tlie  vessels,  except  above  and 
very  close  to  the  papilla.  The  veins  are  dark  red,  almost  black,  and  tortuous 
in  places,  while  the  only  visible  artery  is  small  and  exhibits  a  strikingly  dis- 
tinct reflex  lijjht  streak,  which  indicates  a  commencing  sclerosis  of  the  vessel 
wall.  The  papilla  is  still  fairly  visible  in  this  case,  but  frequently  it  is  in- 
volved in  the  area  covered  by  the  hemorrhage,  wlien  its  margins  are  totally 
hidden.  The  thrombosis  is  a  consequence  of  arteriosclerosis,  or  perhaps  of 
syphilis,  or  of  nephritis,  and  therefore  its  prognostic  signification  is  grave 
(see  page  153). 

•2.  From  the  position.  If  the  hemorrhages  are  not  spread  all  over  the 
fundus,  but  only  occur  along  one  or  more  vessels,  as  shown  in  Fig.  28,  we 
may  speak  of  a  partial  thrombosis,  especially  when  tlie  vessel  itself  shows 
alterations.  The  vascular  changes  could  not  be  studied  in  the  last  picture  on 
account  of  the  enormous  number  of  liemorrhagcs,  but  in  this  one  they  can  be 
studied  very  well.  The  thrombosed  vein  is  broadened  on  the  wiiole,  its  caliber 
varies  in  different  places,  it  is  accompanied  by  abnormal  reflexes,  and  is  filled 
by  a  very  dark,  almost  black,  cohnnn  of  blood.  The  cause  is  arteriosclerosis, 
syphilis,  or  nephritis. 


118 

Isolated  hemorrhages  in  the  niiU-iiln  are  usually  <>f  an  arteriosclerotic 
nature  when  a  high  degret'  of  myopia  is  not  present,  ami  an  injury  can  l)e 
excluded. 

3.  From  the  form.  Little  shuttlelike  hemorrhages,  each  with  a  white 
spot  in  its  center,  are  connnonly  caused  by  such  diseases  of  the  blood  as 
anaemia  and  leucocythaMnia. 

No  definite  etiological  conclusion  can  be  drawn  in  any  other  case  from 
the  condition  of  the  hemorrhage.  In  all  other  cases  the  result  of  the  general 
examination  must  be  awaited.  Such  an  examination  must  be  made  in  those 
cases  that  have  been  mentioned  as  well,  because  the  arteriosclerosis  that  may 
exist  may  be  complicated  by  other  diseases.  The  causes  of  a  retinal  hemor- 
rhage are  very  many. 

The  Causes  of  a  Retinal  Hemorrhage 

The  first  cause  to  be  mentioned  is  an  injury.  It  is  by  no  means  neces- 
sary that  the  eyeball  itself  shall  be  wounded,  hemorrhages  result  from  con- 
tusions, and  are  particularly  common  when  the  eye  has  been  struck  by  a 
ball.  In  these  latter  cases  special  attention  should  be  paid  to  the  macula 
in  the  examination. 

They  are  also  found  after  severe  injuries  of  the  body,  such  as  compres- 
sions of  the  thorax.  They  may  appear  congenitally  as  the  result  of  trau- 
matism during  labor.  More  rarely  they  are  to  be  seen  as  the  result  of  the 
penetration  of  a  foreign  body  into  the  eye,  as  shown  in  Fig.  29.  Emphasis 
is  to  be  laid  on  the  word  "seen"  in  this  connection,  as  they  are  often  present 
though  invisible  because  of  the  hemorrhage  that  takes  place  into  the  vitreous 
at  the  same  time. 

Their  most  important  cause  is  arteriosclerosis,  and  in  these  cases  they 
are  of  very  great  prognostic  value  because,  in  at  least  .507c,  they  are 
forerunners  of  hemorrhage  into  the  brain  (see  page  153).  These  hemor- 
rhages have  been  studied  already  under  the  forms  of  total  and  partial  throm- 
bosis of  the  central  vein,  and  of  the  isolated  hemorrhage  in  the  macula,  but 
they  are  also  found  distributed  about  in  the  retina  as  diffuse  spots,  which 
give  a  very  bad  prognosis  with  regard  to  the  later  onset  of  apoplexy,  from 
80  to  lOO'/c,  while  a  thrombosis  is  followed  by  apoplexy  in  only  about  50/i  . 
Finally,  it  may  be  mentioned,  for  the  sake  of  completeness,  that  arterioscle- 
rosis may  manifest  itself  through  a  hemorrhage  into  the  vitreous. 

Reference  is  to  be  made  to  the  chapter  on  "The  Changes  in  the  Vessels 
of  the  Retina,"  and  the  very  careful  study  of  these  vessels  is  urged  upon 
the  reader. 

Diabetes  and  nephritis,  especiaUy  tke  form  of  the  latter  characterized 
by  the  granular  atrophy  of  the  kidney,  are  very  important  causes  both  of 
little,  stippled  hemorrhages,  and  of  'large,  lakelike  ones ;  both  forms  usually 
appear  at  the  same  time  with  white  spots,  or  disease  of  the  optic  nerve,  so 


119 

the  description  of  them  is  reserved  for  a  later  cliapter.  This  etiology  is 
always  to  be  borne  in  mind  when  the  hemorrhages  are  isolated. 

Syphilis  is  likewise  one  of  the  principal  causes  of  retinal  hemorrhages, 
but  other  manifestations  of  the  disease  are  usually  present. 

All  of  the  remaining  causes  are  much  less  frequent.  First  among  tluin 
come  tlie  diseases  of  the  blood.  It  has  already  been  said  tiiat  these 
hemorrhages  often  present  a  special  form,  a  spindle,  or  shuttle  shape  with 
a  white  spot  in  the  center,  yet  they  may  not  have  this  peculiarity,  but  may 
appear  simply  as  small  spots  and  stripes.  Hemorrhages  are  rarely  met  with 
in  chlorosis,  they  are  more  common  in  pernicious  ana'mia,  and  occur  most 
often  in  leucocytha-mia,  chiefly  in  the  form  of  stri.-e.  In  well  marked  cases 
of  the  last  mentioned  disease  the  orange  tone  of  the  fundus  and  the  great 
breadth  of  the  vessels  arc  diagnostic. 

Similar  hemorrhages  are  also  observed  in  simple  an<pmia  following  a  great 
loss  of  blood,  and  in  ha^iiophilia. 

It  hardly  needs  to  be  said  that  they  occur  in  the  hemorrhagic  diathe- 
sis, as  well  as  in  purpura,  scurvy,  purpura  ha'morrhagica,  and  Barlow's 
disease,  but  they  are  of  comparatively  little  importance  in  these  diseases, 
as  they  are  all  rare. 

The  appearance  of  hemorrhages  is  of  considerable  importance,  on  the 
contrary,  in  the  acute  infectious  diseases,  such  as  malaria,  typhoid  fever, 
influenza,  miliary  tuberculosis,  and  sepsis,  though  they  are  not  so  very  fre- 
cjuent  in  them.     Sometimes  they  are  to  be  seen  in  cancerous  cachexia. 

Conditions  that  need  to  be  differentiated  from  retinal  hemorrhages  are: 

1.  Lacerations  in  an  opaque,  detached  retina.  These  lie  at  a  deeper  level 
than  their  surroundings,  as  can  be  proved  by  parallactic  displacement,  have 
a  distinctly  opaque,  gray  margin,  and  sometimes  allow  the  markings  of  the 
chorioid  to  be  seen  through  them. 

2.  Hemorrhages  in  the  chorioid.  These  are  rare  and  demonstrable  only 
when  the  fundus  contains  little  pigment.  The  vessels  of  the  retina,  and 
perhaps  of  the  chorioid,  pass  over  them.  Other  changes  are  general! v  present 
in  the  chorioid.  They  are  of  practical  importance  onlv  in  mvopia  and 
eclampsia. 

3.  The  cherry  red  spot  in  occlusion  (;f  the  central  artery  (see  page  1.50). 
The  demonstration  of  an  acute,  dirt'use  cloudiness  of  the  retina  in  these  cases 
makes  the  diagnosis  certain. 

4.  Spots  of  pigment.  These  are  dark  and  usually  are  found  in  company 
with  changes  in  the  chorioid. 

5.  The  traumatic  perforation  of  the  macula.  This  is  rare  and  is  char- 
acterized by  a  circular  blood  red  disk  in  the  macula,  about  two  thirds  the 
size  of  the  papilla,  that  looks  as  if  cut  out  w  ith  a  punch. 

As  the  so-called  recurrent  hemorrhage  into  the  vitreous  is  looked 
upon  by  many  autiiors  as  a  hemorrhage  from  the  retinal  vessels,  it  shoidd 
be  mentioned  in  this  place.     This  is  met  with  in  young  persons,  usuall}'  males, 


120 

and  lias  tlic  unpleasant  tondtiuv  to  recur  tliat  is  impliid  Ijy  the  iiainc.  Tlie 
real  cause  is  unknown,  though  it  has  hcin  supposed  to  be  due  to  an  early, 
localized   arteriosclerosis. 


(b)  Hemorrhage  into  the  Retina  as  an  Accompanying  Symptom 
of  Disease  of  the  Optic  Nerve  (without  white  or  black  spots) 

Glaucomatous  Excavation. 

As  soon  as  the  media  have  cleared  up  sufficiently,  after  an  acute  attack 
of  glaucoma,  to  allow  the  details  of  the  fundus  to  become  visible  again, 
hemorrhages,  varying  in  form  and  number,  can  be  sch-ii  in  addition  to  the 
excavated  papilla  and  the  more  or  less  altered  blood  vessels.  Usually  they 
form  little  linear,  or  blotlike  spots,  which  radiate  from  the  papilla  far  out 
into  the  periphery.  The  prognosis  is  generally  bad  in  such  a  case  of 
glaucoma. 

In  this  connection  may  be  mentioned  the  hemorrhages  that  take  place 
after,  or  during  operations  on  glaucomatous  eyes  as  the  result  upon  the 
vessels  of  the  sudden  fall  of  the  intraocular  tension. 

Optic  Neuritis. 

Hemorrhages  are  found  near  the  papilla  in  optic  neuritis  from  all  manner 
of  causes,  but  the}'  are  particularly  common  in  that  due  to  nephritis  and 
diabetes.  The  great  diagnostic  importance  of  these  hemorrhages  was  pointed 
out  when  speaking  of  the  so-called  pseudoneuritis.  The  presence  of  a  single 
minute  hemorrliage  in  a  doubtful  case  of  pseudoneuritis  or  optic  neuritis 
immediately  renders  the  latter  diagnosis  positive. 

Choked  Disk. 

Fine,  striated  hemorrhages,  which,  from  their  form,  must  lie  in  the  layer 
of  nerve  fibers,  form  an  almost  regular  feature  of  choked  disk. 


PLATE  XV 

Fig.  27.     Occlusion  of  the  Central  Vein  of  the  Retina  (Apoplexia 

Sanguinea  Retinae) 

Fig.  28.     Occlusion,    or   Thrombosis,    of    a    Single   Vein    of    the 

Retina 


Fig.  27.— Occlusion  of  the  Central  Vein  of  the  Retina  (Apoplexia 

Sanguinea  Retinae) 

(S(.(.'  jiii^t'  1  IT) 

The  striated  iirraiif^ement  of  tlie  4ieiiiorrlia^es  sliows  tliat  they  are  situ- 
ated in  till'  most  superficial  layers  of  tlu'  retina.  'I'he  portions  of  the  I'etina 
that  lie  between  the  hemorrhages  are  sliirhtly  (edematous  (see  page  IIT). 

The  vessels  are,  for  the  most  part,  eoiicealeii  by  tlii'  hemorriiages,  and 
are  also  in  part  thrombosed,  so  that  only  those  in  tlu-  jiortions  closely  adja- 
cent to  the  papilla  are  visible. 

The  papilla  itself  is  not  materially  changed,  but  it  may  be  covered  by 
the  hemorrhages. 

The  cause  of  such   an  occlusion   is  nephritis,  or  arteriosclerosis   in   most 


cases. 


Fig.    28. — Occlusion,    or   Thrombosis,    of    a    Single   Vein    of    the 

Retina 

(See  page  117) 

The  changes  in  the  vessels,  which  could  not  be  seen  in  the  preceding 
picture  because  of  the  profuse  hemorrhages,  can  be  perceived  quite  well 
in  this  one. 

The  thrombosed  vein  is  very  broad,  is  of  a  deep,  dark  red,  fluctuates  a 
great  deal  in  caliber,  has  abnormal  reflexes  and  has  a  marked  tortuosity. 

The  hemorrhages  are  in  the  innnediatu  vicinity  of  the  diseased  vessel 
and  thereby  betray  the  cause  of  the  change. 

The  arteries  are  normal  in  these  cases,  yet  the  afferent  branch  is  fre- 
quentl}-  small  (see  page  117). 


122 


Tab.  15. 


Fig.  27. 


Fi.e.  28. 


PLATE  XVI 

Fig.  29.     Foreign  Body  in  the  Retina  and  Chorioid 


Fig.  29.     Foreign  Body  in  the  Retina  and  Chorioid 

Tln'  liltlr.  irrav,  sil\rrv  hit  of  sti'cl  (lid  not  have  force  enough  to  jjcrforate 
the  evehiill  a  second  fiiiic;  it  could  only  tear  its  way  into  the  retina  and 
chorioid,  wlicre  it  remains. 

The  torn  phice  is  partially  covered  by  a  hemorrhage  and  is  surroundid 
b}'  an  (edematous,  gray  oval.  I'his  ])iece  of  steel  was  removed  by  means  of 
a  magnet  and  good  vision  was  j)reserve(l.  hut  the  hitter  may  be  badly  impaired 
by  the  onset  of  a  detachment  of  the  retina.  The  picture  is  usually  wry 
indistinct,  because  of  an  accompanying  luniorrhage  into  the  vitreous;  if  this 
latter  is  absent  it  is  generally  possible  to  obtain  a  glimpse  of  the  foreign  body. 


12i 


Tab.  IG. 


Fig.  29. 


125 


II.    WHITE  SPOTS   IN  THE  FUNDUS 

Question  1 
Is  the  White  Spot  in  the  Retina,  or  in  the  Chorioid? 

{Differential  Diagnosis  hctxceen  Retinal  and  Chorioidal  iSpots) 

Unfortuii.ittlv  tliurc  is  no  qiiiti^'  exact  ruk'  by  which  it  can  1)l'  determined 
positively  in  ever>-  case  whether  a  certain  white  spot  in  the  fundus  is  in  the 
retina  or  in  the  chorioid.  The  reason  why  is  apparent  wlien  we  consider 
that  in  many  cases,  as  in  the  case  of  miliary  tuberculosis  pictured  in  Fig.  81, 
we  do  not  see  the  chorioidal  affection  itself,  but  have  to  be  satisfied  with 
the  observation  of  the  secondary  symptoms  which  are  produced  b}'  a  lesion 
in  the  chorioid  upon  the  retina  that  lies  over  it,  for  example,  of  a  circum- 
scribed oedema.  Still,  in  spite  of  the  fact  that  we  can  see  onh'  the  secondary 
symptoms  in  the  retina,  we  can  make  the  diagnosis  of  tubercle  of  the  chori- 
oid in  this  case,  because  our  clinical  and  pathological  experience  is  that 
under  certain  conditions  of  high  fever  and  stupor  the  appearsuice  of  circum- 
scribed patches  of  I'etinal  (rdema  in  tile  fiuidus  are  inilicative  of  tubercle 
of  the  chorioid.  We  nmst  be  guided  many  times  in  this  way  by  our  general 
clinical  and  pathological  experience  in  deciding  whether  the  lesion  is  in  the 
retina,  or  in  the  chorioid,  but  this  may  fail  if  we  do  not  use  at  the  same 
time  our  special  ophthalmological  knowledge.  Spots  may  appear  in  sepsis, 
and  therefore  be  attended  by  quite  similar  general  symptoms,  which  may 
seem  very  like  those  of  miliary  tuberculosis,  but  they  are  situated  in  tjie 
retina,  as  has  been  proven  by  pathological  examination.  Hence  the  general 
symptoms  may  guide  us  wrongly  in  these  cases  if  we  do  not  know  that  hemor- 
rhages occur  far  more  often  in  septic  retinitis  than  in  miliary  tuberculosis, 
while  on  the  other  hand,  a  simultaneous  involvement  of  the  optic  nerve  points 
rather  to   the  latter. 

I  do  not  wish  to  make  a  cai-cful  observer  timid,  or  to  stump  a  young 
ophthalmologist  with  such  an  unsatisfactory  case,  but  only  to  show  him  by 
this  example  that  the  answer  to  the  question  xchethcr  the  lesion  is  in  the  eho- 
rioid  or  in  the  retina,  is  not  to  he  learned  through  the  vision  alone:  it  is  to 
he  ohtained  only  from  the  most  careful  consideration  of  the  other  conditions 
in  the  eye  and  the  utilization  of  genercd  clinical  and  pathological  knozcledge. 

A  number  of  SA-mptoms  can  always  be  found  whicii  will  make  the  diagnosis 
certain  in  one  way  or  another  in  any  given  case.  When  we  sec,  for  example, 
in  Fig.  38,  that  the  white  spot  lies  partially  over  a  vessel  in  the  retina,  we 
know  positively  that  the  lesion  is  retinal,  and  when,  on  the  other  hand,  we 
see  in  Fig.  74  that  the  patch  is  surrounded  by  a  beautiful  wreath  of  pigment, 
we  need  nothing  more  to  prove  that  the  disease  is  of  the  chorioid.  Unfor- 
tunately these  positive  signs  are  not  always  present ;  in  Fig.  31   the  vessels 


\26 


of  tlio  iTtina  run  over  the  vhite  spots,  and  in  Fio-.  81  tlic  wliite  s])()ts  have 
no  [jignientcd  borders,  yet  in  the  one  tlic  lesion  is  in  the  retina,  and  in  the 
other  ill  the  cliorioid.  Therefore  we  lia\e  to  ditl'erentiate  hetween  tiiose  symp- 
toms that   are  trust wortiiv,  or  nearly  so,  and  those  that  are  adjuvant. 


Differentiation  hettreen  Lesions 
in  tlie  Cliorioid  (ind  the  Retina. 

1.    Trusixcortliii    sijmptoms.      These    can    he    accepted    only    in 

sense,  i.e.,  their  absence  does  not   prove  thi'  contrary. 

Ncti/itil  Lesion  Chorioidal  Lesion 

1.  The  partial  covering  of  a  leti- 
nal  vessel  by  a  white  spot  (  Fit;-.  38 )  ■ 

2.  A   stellate   form   in  the  macula 
(Fi-.   34). 


|>ositivc 


1.  Pigment  deposited  about  or  on 
the  sjwt  (Fig.  71). 

2.  The  demonstration  of  chori- 
oidal vessels,  whether  sclerosed  or 
not,  in  the  spot   (Fig.  64). 

.3.  A  markedly  cresccntic  form,  as 
in    Fig.   83. 


3.  The  demonstration  of  liemor- 
rhages  in  the  retina,  and  of  changes 
in  the  retinal  vessels  is  relatively  cer- 
tain  (Fig.  35). 

N.  B. — If  both  varieties  of  spots  are  found  in  any  case,  changes  are 
probably  present  in  both  membranes;  thus,  in  Fig.  50,  the  retinal  vessels 
are  partly  covered  by  the  spot,  and  yet  there  are  heaps  of  pigment  at  its 
upper  margin.  In  this  case  there  was  a  fresh  disease  of  the  retina,  glioma, 
and  an   older  disease   of  the  chorioitl,   perhaps  due   to   hereditary   syphilis. 

2.  Adjurinit   St/mptoms: 

Uctinal  Lesion  Chorioidal   Lesion 

Bright,   often   brilliant   white.     Fresh:  yellowish,  reddish  yel- 
Color:  more     rarely    yellowish     or  low,    slightly    gray.       Old: 

reddish.     Edematous  spots  white,  but   with  pigment, 

gray. 

formed    by 
of    smaller 


Size: 


Position : 


Visibility  of 
the  vessels 
of  the  cho- 
rioid : 


Usually   small,   or 
the    confluence 
spots. 


A'ariable.  A  large  white 
patch  below  (in  the  invert- 
ed image  above)  the  optic 
nerve  indicates  a  coloboma 
of  the   chorioid. 

Very  rarely  in  the  periphery.     Often   in   the  j)eriphery. 

In  the  case  of  a  tesselated  or     In    the    case    of    a     uniform, 


albinotic  fundus  the  vessels 
of  the  chorioid  are  usually 
invisible  in  the  vicinity  of 
the  change  in  the  retina 
because  of  the  opacity  of 
the  elsewhere  transparent 
membrane   (Fig.  22). 


stippled  fundus  the  vessels 
of  the  chorioid  stand  forth 
and  indicate  early  changes 
in  that  membrane.  Notice 
the  partially  albinotic  fun- 
dus in  Fig.  57. 


127 

In  spite  of  all  this  hulp  there  remains  quite  a  number  of  cases  in  which 
the  diagnosis  may  be  doubtful,  and  it  is  necessary  that  wc  should  be  acquainted 
with  these  in  order  to  avoid  falling  into  error. 

(a)  Changes  in  ihc  Hi-thui. 

1.  The  coronnhi,  in  a  case  in  which  a  total  occlusion  of  the  central  artery 
took  place  at  some  former  time.  A  number  of  fine  bright,  yellow  or  reddish 
spots  are  to  be  seen  arranged  in  a  circle  in  the  macula,  and  are  usuilly 
surrounded  by  a  slight  pigmentation  (Fig.  16)-  The  coi-rect  diagnosis  i; 
indicated  by  the  atrophy  of  the  optic  nerve  and  the  extreme  smallness  of 
the  retinal  arteries. 

(b)  Changes  in   the  Chorioid. 

1.  Aside  from  this  circular  arrangement,  arteriosclerotic  changes  in  the 
macula  (Fig.  62)  may  form  an  ophthalmoscopic  picture  which  is  quite  similar 
to  that  presented  by  the  corcnula.  The  results  of  the  general  examination, 
the  other  arteriosclerotic  changes  in  the  eye,  and  the  age,  must  all  be  taken 
into  account  in  making  the  diagnosis.  These  changes  arc  due  to  a  circum- 
scribed Jiyaline  degeneration  of  the  choriocapillaris. 

2.  Colloid  Formations  on  the  Vitreous  Lamella  (Fig.  41).  These  appear 
as  little,  bright  points,  of  a  yellowish,  or  yellowish  gray  color,  which  can  be 
differentiated  from  the  typical  spots  in  the  retina  by  their  color  and  by  the 
indistinctness  of  their  outlines.  Pathologically,  they  are  small,  knoblike  thick- 
enings of  the  vitreous  lamella  of  the  chorioid,  which  mechanic;dly  destroy  the 
pigment  epithelium  at  the  places  where  they  exist.  But,  as  this  leads  in 
turn  to  accunudations  of  pigment,  little  black  lumps  can  generally  be  seen 
in  their  vicinity. 

3.  Little  Foci  in  Sympathetic  Inflammation  (Fig.  40).  Little  sharply 
defined  spots,  whitish,  yellowish  white,  or  reddish  yellow  in  color,  are  to  be 
seen  sometimes  in  the  periphery  of  the  fundus  of  an  eye  that  is  sympathet- 
ically inflamed.  They  are  usually  round,  more  rarelv  oval,  and  have  little 
tendency  to  blend.  Sometimes  there  is  a  brownish  tesselation  in  their  vicinity? 
although  a  true  pigmented  edge,  or  a  marked  accumulation  of  pigment,  is 
absent.  For  this  reason,  which  indicates  a  retinal  affection,  some  authors 
believe  these  spots  to  belong  in  fact  to  the  retina,  but  we  must  look  upon 
them  as  appertaining  to  the  chorioid  because  of  the  nature  of  the  disease 
as  a  whole,  and  because  of  the  anomalies  of  pigment  occasionallv  to  be  ob- 
served. When  other  symptoms  of  sympathetic  intlannnation  are  jiresent  at 
the  same  time  the  diagnosis  cannot   fail  to  be  made. 

N.  B. — Attention  must  be  called  to  a  possibility  of  error  that  arises 
from  mistaking  reflections  from  the  retina  for  pathological  changes.  These 
may  appear  just  like  little  yi'llowisli  patches  in  the  macula,  but  thev  disappear 
when  the  pupil  is  dilated  and  the  examination  is  made  by  the  direct  method. 
They  also  change  their  forms  when  the  mirror  is  rotated. 

After  the  diagnosis  of  a  disease  of  the  retina  has  been  established  in  the 
above  manner  there  arises 


128 

Question  2 
Is  This  a  Case  of  Medullated  Nerve  Fibers  or  Not? 

Mc'dulliiti'd  nerve  fibers  occupy  ii  unique  position  anion^  the  .iffVctions  of 
the  retina,  so  it  seems  best  to  deal  with  them  separately.  The  entire  nature 
of  tlie  condition  is  expressed  by  the  term  nuchiMatrd  nerve  til)ers,  wiiilc  all 
other  white  spots  in  the  retina  are  only  symptomatic  of  causes  that  must  be 
ascertained  through  other  conditions. 

DiagnoKis  and  Imporlaiirc  of 
Mfdullaii'd  Nei've  Fibers. 

Medullated  nerve  fibers  (Fig.  9)  are  quite  superficial,  in  hai-niony  with 
their  anatomical  development,  and  thus  partly  cover  the  vessels  of  the  retina. 
They  radiate  from  the  papilla  and  show  a  more  or  less  distinct  fii)rillati(in, 
corresponding  to  the  course  and  the  construction  of  the  fibers,  which  is 
particularly  evident  at  the  margins  of  the  patches  that  they  form,  where  they 
often  terminate  in  a  fiamelike  figure.  They  are  for  the  most  j)art  slightly 
yellowish  in  color,  and  connnonly  are  in  immediate  connection  with  the  papilla, 
though  occasionally  separated  from  it,  when  they  follow  the  course  of  the 
large  vessels.  The  diagnosis  is  somewhat  more  difficult  in  the  latter  cases, 
but  the  difficulty  is  removed  by  observation  of  the  markings  of  the  fibers  and, 
above  all,  by  the  absence  of  any  other  lesion.  The  great  stress  that  is  to 
be  laid  on  the  latter  condition  is  shown  by  the  lesion  pictured  in  Fig.  32,' 
which  agrees  throughout  with  the  description  given  of  medullated  nerve  fibers, 
although  it  rarely  happens  that  such  fibers  overlap  the  entire  margin  of  the 
papilla,  but  is  proved  not  to  be  such  by  the  little  hemorrhages  at  the  margin 
of  the  lesion. 

Medulhited  nerve  fibers  foi-m  a  congenital  anomaly  and  are  therefore  of 
no  other   clinical   importance. 

After   these  lia\e   been   excliidid   conies 


Question  3 
Of  What  Nature  Are  the  Spots  in  the  Retina? 

This  question  must  lie  divided  into  two:  1,  with  regard  to  the  pathology; 
2,  with  regard  to  tiie  etiology  of  the  spots.  The  spots  may  differ  greatly 
ill  their  pathological  construction,  and  yet  arise  from  the  same  causes,  or, 
on  the  other  hand,  they  may  be  due  to  quite  different  causes  and  present  the 
same  pathological  picture. 


129 


Question  I/. 

In  how  far  can  the  Pathological  Construction  of  a  Spot  be  Deter- 
mined from  the  Ophthalmoscopic  Picture? 

Differential   Dtugnosis   of   White  Spots  from   a    I'atIii)lo(/iriiJ   Standjioiin 

Leaving  mcdullatud  iktvl'  fibers  out  of  consideration,  white  spots  may  be 
due  to  connective  tissue,  to  proliferation  of  the  glia,  to  varicose  thickening 
of  the  layer  of  nerve  fibers,  to  fatty  degeneration,  to  wdema,  to  fibrinous  or 
serous  exudates,  to  deposits  of  calcareous  matter,  or  to  hyaline  degeneration. 

1.  Connective  Tissue  (Figs.  36  and  37)- — The  presence  of  connective  tis- 
sue always  indicates  that  a  serious  disturbance  has  taken  place  in  the  retina, 
except  in  the  rare  cases  in  which  it  is  present  congenitally.  In  the  majority 
of  cases  it  starts  from  the  vessels,  or  from  their  adventitial  sheaths,  and 
consequently  is  almost  always  seen  in  connection  with  vessels  that  are  either 
pathologicalh'  changed  or  newly  formed.  These  are  cases  of  retinitis  pro- 
liferans. 

The  development  of  connective  tissue  is  caused  by  hemorrhages,  or,  in  a 
small  number  of  cases,  by  lacerations  of  the  chorioid  and  retina.  Tliese 
naturally  present  no  typical   arrangement   (Fig.   82). 

The  color  is  like  that  of  medullated  nerve  fibers,  except  that  it  is  rather 
duller,  and  thev  often  have  a  similar  striated  structure.  Usually  it  can  be 
determined  by  parallactic  displacement  that  they  project  above  the  level  of 
the  retina.  Aside  from  the  tilings  already  mentioned,  arteriosclerosis  plays 
the  most  important  part  in  tiieir  etiology,  then  comes  syphilis,  and,  in  the 
third  place,  diabetes.  In  the  latter  disease  the  masses  of  connective  tissue 
are  particularly  well  marked  and  project  far  into  the  vitreous,  as  in  Fig.  36. 

2.  (Edema. — Only  those  cases  in  which  the  a?dema  is  circumscribed  are 
included  here;  those  in  which  it  is  diffuse,  as  it  usually  is,  do  not  enter  into 
the  question  (for  these  see  page  149). 

The  diagnosis  is  particularly  difficult  when  wdema  occurs  at  the  same 
time  with  other  affections  of  the  retina,  but  its  presence  may  be  suspected  in 
every  serious  retinal  disease. 

The  diagnosis  is  easy  only  when  it  occurs  in  isolated  patches.  It  is  then 
usuallv  found  over  fresh  choriorctinitic  lesions,  especially  tubercle  nodules, 
wiien  it  manifests  itself  in  the  form  of  medium-sized,  roundish  spots  of  a 
light  gray  color,  with  obliterated  margins  and  a  distinct  elevation,  wiiich 
can  be  determined  particularly  well  when  retinal  vessels  pass  over  it  (Fig- 
78).  Although  only  the  oedema  of  the  retina  is  to  be  seen  in  such  cases  we 
are  accustomed  to  make  from  it  tlie  diagnosis  of  a  lesion  in  tlie  chorioid. 

3.  The  varicose  thickening  of  tlie  lai/er  of  nerve  fibers  has  the  same  sub- 
stratum  as   the  medullated   nerve  fibers   and  often   resembles   the  latter  very 


130 

closely.  The  altcnd  fibers  are  of  i\  light,  golden  wliite,  have  a  certain  liril- 
liancv  in  places,  and  radiate  in  striie  from  tlie  papilla.  This  chantre  is  met 
with  in  tile  greatest  variety  of  diseases,  as  a  local  piienomenon  of  neiii'o- 
retinitis  of  albuminuric  and  other  origin,  in  choked  disk,  in  diseases  of  the 
vessels,  and  so  on.  It  often  covers  or  envelops  the  vessels  of  the  retina  as 
it  is  quite  superficial  in  its  situation  (Fig.  32). 

4.  Fdttt)  Degeneration. — This  is  certainly  the  principal  cause  of  the  whit" 
spots.  To  it  are  to  be  ascribed  the  white  spots  ordinarily  to-  be  seen  in 
albuminuric  retinitis.  They  appear  ophthalmoscopicaliy  as  yellowisii,  or  pure 
white  (Figs.  30  !ind  31))  small,  roundish  patches  which  often  blend,  and  so 
produce  large  spots.  They  lie  mainly  in  the  intei-granular  layer  and  have 
a  special  predilection  for  Mueller's  supporting  fibt'rs.  The  vessels  of  the 
retina  may  be  seen  to  glide  over  these  patches.  The  granules  of  fat  are  also 
to  be  found  iti  the  layer  of  nerve  fibers,  the  layer  of  ganglion  cells,  and  the 
internal  granular  la^-er,  but  to  a  much  less  degree;  they  are  never  present 
in  the  layer  of  yisual  cells,  or  in  the  outer  granular  layer,  which  have  a 
different  nutritive  supply  (see  page  113). 

The  stellate  figure  in  the  macula  is  brought  about  by  the  fatty  degenera- 
tion of  the  supjjorting  fibers,  or,  according  to   others,  of  Henle's  layer. 

This  fattj'  degeneration  is  met  with  in  all  manner  of  diseases,  but  chicfiy 
in  nephritis  and  diabetes. 

5.  Fibrinous  exudates  may  lie  in  any  or  the  inner  layers  of  the  retina 
and  consequently  may  be  in  various  relations  to  the  blood  vessels.  The  spots 
thus  produced  are  larger  than  those  caused  by  fatty  degeneration,  and  some- 
times they  induce  a  slight  elevation  of  the  ])art  affected  (Figs.  38  and  39). 
When  they  are  superficial  they  are  of  a  light  blue  white  color  and  look  as 
if  they  ^vere  loosened  up,  like  bits  of  cotton. 

N.  B. — Sometimes  little  glittering  points  or  needles  can  be  seen  in  the 
retina.  These  are  crystals  of  cholesterin,  such  as  are  to  l;e  seen  sometimes 
floating  in  the  vitreous.  When  tlie  latter  are  situated  in  the  most  posterior 
layers  of  the  vitreous  they  may  perhaps  simulate  s])ots  in  the  retina,  but  their 
great  parallactic  displacement,  and  the  fact  that  they  can  be  seen  when  we 
simply  throw  light  into  the  eye,  prove  them  to  be  what  they  are,  the  so-called 
synchisis  scintillans. 

None  of  the  otiier  pathological  changes  mentioned  above  can  be  recog- 
nized with  certainty  from  the  ophthalmoscopic  picture. 

The  Course 

of  the  changes  that  have  been  mentioned  is  usually  very  slow.  In  mild 
cases  the  symptoms  undergo  involution  after  some  weeks  and  the  eye  may 
return  to  its  normal  condition,  both  functionally  and  ophthalmoscopicaliy. 
The  little  white  spots  caused  by  fatty  degeneration  gradually  become  redder, 
ill  defined,  and  tin  n  blend  with  their  surroundings.  Fresh  spots  are  therefore 
bright  white  and  nIku  ply  defined,  while  older  ones  are  reddish  and  ill  defined. 


1.31 

A  prolonged  duration  of  tlic  distiisc  finally  injures  the  nervous  elements 
moi-e  or  less,  so  that  at  least  an  impairment  of  the  functions  remains,  and  in 
many  cases  changes  are  left  that  can  he  seen  with  the  opht  h;ihiic)--ciipi',  such 
as  a  migration  of  j)igment  into  the  atrophic  retina,  changes  in  the  vessels,  and 
atrophy  of  the  optic  nerve. 

In  other  cases  atrophy  of  the  papilla  results  from  atroj)hy  of  the  nerve 
fibers.  A  case  is  pictured  in  Fig.  16  in  which  a  destruction  of  the  nerve  fibers, 
and,  as  a  result,  an  atrophy  of  the  optic  papilla,  was  caused  by  an  occlusion 
of  the  central  artery.  Pigment  cells  have  migrated  into  the  atrophic  retina 
around  the  papilla  and  in  the  region  of  the  macula.  In  other  cases  the 
change  may  be  located  very  near  the  papilla,  as  in  Figs.  32  and  33,  when 
the  consequently  atrophied  disk  will  probably  show  very  indistinct  margins. 

In  still  other  cases  such  a  picture  may  finally  be  produced  by  the  increase 
of  the  changes,  as  that  shown  in  Fig.  34. 

Sometimes  bands  of  connective  tissue  may  be  seen  to  appear  together  with 
the  advancing  atrophy  of  the  retina,  as  in  Fig.  36- 

A  description  of  these  that  is  generally  applicable  cannot  be  given. 

Question  5 

In  how  far  can  a  Conclusion  be  Drawn  from  the  Ophthalmoscopic 
Picture  Concerning  the  Etiology  of  White  Spots? 

Differential  Diagnosis  of  White  Spots  from  the  Etiological  Standpoint 

As  the  etiology  of  the  white  spots  may  vary  greatly,  and  as,  on  the  other 
hand,  the  cause  of  the  spots  cannot  be  ascertained  in  this  way  alone,  the 
final  decision  as  to  the  etiology  must  be  left  to  the  results  of  a  general 
examination.  It  must  always  be  borne  clearly  in  mind  that  the  eye  is  not 
an  organ  standing  alone  by  itself,  but  that  it  is  a  part  of  the  entire  body, 
and  that,  with  few  exceptions,  the  diseases  of  the  fundus  arc  simply  symp- 
toms of  general  diseases.  It  is  as  true  of  white  spots  as  it  is  of  hemorrhages 
that  they  are  signals  of  warning  to  show  us  that  danger  threatens.  The 
retina,  with  its  very  complicated  structure  and  its  highly  developed  func- 
tions, is  a  specially  fine  reagent  to  a  great  many  disturbances  of  the  general 
organism. 

Our  duty  is  therefore  imperative,  just  as  it  is  in  cases  of  hemorrhage  into 
the  retina,  to  make  a  thorough  examination  of  the  bod?/,  particularli/  of  the 
urin£  and  of  the  blood.  If  nothing  is  found  on  the  first  examination,  some- 
tliing  may  be  detected  on  the  second,  for  the  change  in  the  retina  precedes 
the  other  symptoms  in  many  cases,  but  it  is  rarely  misleading. 

Von  Michel  frequently  told  of  a  case  in  which  he  made  the  diagnosis  of 
albuminuric  retinitis,  although  the  family  physician  could  discover  no  albumin 
in  the  urine  in  spite  of  repeated  examinations;  it  was  not  until  after  the 
urine   had   been   precipitated    that   some   granular   casts    were    found,    and    yet 


V.V2 

tlie  patient  died  two  years  later  with  tlie  syiiiptonis  referalili^  to  a  eoil- 
tracted  kidney. 

What  was  said  above,  tliat  in  tlie  determination  of  the  etiology  of  a  disease 
of  tlie  retina  reliance  must  be  placed  exclusively  on  the  results  of  the  general 
examination,  must  not  be  taken  literally,  for  I  he  expert  can  certainly  make 
the  etiological  diagnosis  in  many  cases  from  the  oplithalinoscopic  picture — 
provided  that  the  change  in  the  retina  is  typical.  This  is,  unfortunatel}', 
not  always  the  case,  so  the  statement  generally  holds  good,  even  for  the 
expert. 

VVe  will  now  try  to  ascertain  what  characteristics  are  jieculiar  to  the 
'^dividual  forms,  but  it  must  be  stated  again  that,  of  the  wiiole  number  of 
changes  described,  none  may  perhaps  be  present,  except  one  or  two  minute 
white  s[)()ts,  or  a  small  hemorrhage.  We  will  first  di\  ide  the  cases,  according 
to  an  outward  clinical  symptom,  into 


(a)  Bedridden,  Febrile  Patients   (Retinitis  Septica) 

The  internist  knows  that  typhoid  fever,  miliary  tuberculosis,  tuberculous 
meningitis,  and  sepsis  can  be  dittereiitiated  with  the  ophthalmoscope.  T.et  us 
suppose  that  we  have  been  called  into  consultation  over  such  a  patient,  who 
has  high  fever  and  no  characteristic  symptoms.  What  is  to  be  expected 
from  us.-* 

In  sejisis  we  find  in  the  fundus  near  the  papilla,  never  in  or  near  the 
macula,  mediuni-si/ed,  roundish,  or  oval  white  spots,  and  similar  hemor- 
rhages, but  they  do  not  lie  regularly  in  the  vicinity  of  the  vessels,  as  in 
thrombosis.  In  many  cases  the  hemorrhages  are  very  large  and  extensive, 
often  so  as  to  cover  the  blood  vessels. 

In  typhoid  fever  wo  never  find  such  white  spots  and  rarely  luinorrhages. 
It  is  self-evident  that  these  may  sometimes  be  absent  in  sepsis,  so  it  is  only 
the  positive  condition  that  is  diagnostic. 

In  tuberculous  meningitis  we  generally  find  an  optic  neuritis,  like  that 
shown  in  Fig.  81- 

In  niiliai-y  tubi-rculosis,  on  the  contrary,  we  find  yt'llowish,  or  yellowish 
gray  spots,  as  rejireseiited  in  the  same  picture,  and  as  they  have  been  de- 
scribed under  tubercle  of  the  chorioid  (page  180).  The  picture  was  taken 
from  a  case  of  miliai'v  tuberculosis  which  j)rovetl  on  autopsy  to  be  also  one 
of  a  severe  meningitis. 

The  importance  of  ophthalmoscopy  in  the  difll'erential  diagnosis  of  the 
above  diseases  has  been  decreased  a  good  deal  by  the  introduction  of  such 
specific  reactions  as  that  to  tuberculin  and   Wiihil's. 


1:53 


(b)  Nonfebrile  Patients 

1.  Retinitis  cilhnminuricn.  This  comes  first  in  importance.  The  beautiful 
picture  of  the  stellate  pgure  in  the  Jiuieula  (Fig.  34)  is  so  impressed  on  the 
minds  of  most  students  that  iliet/  expect  to  find  it  in  everi)  case  of  tliis  disease, 
and  ijet  it  is  met  xcith  only  exceptionalli/;  ordinarUi)  ice  sec  onlij  single  u-hite 
spots  of  the  form  and  size  depicted  in  Fig.  31. 

Tile  characteristic  signs  of  an  albuminuric  retinitis  are  as  follows: 

(a)  Signs  on  or  about  the  papilla,  such  as  an  optic  neuritis  with  a  large 
or  a  small  white  r'uiij;  (Figs.  32  and  33).  but  these  may  be  absolutely  absent, 
as  in  Figs.  30  ami  31. 

{/^)  Hemorrhages,  both  striated  (Fig.  32)  and  punctate  (Fig.  31)-  These 
likewise  may  be  lacking  in  any  given  case  (Fig.  30)- 

(y)  Little  white  spots  in  and  about  the  macula  (Figs.  30  and  31  )•  These 
also  may  not  be  present. 

(5)  The  stellate  figure  in  the  macula  (Figs.  30  and  34),  but  this  is  by 
no  means  always  present  and  it  may  be  met  with  in  other  diseases. 

These  pictures  are  shown  for  the  purpose  of  demonstrating  that  those 
things  which  give  the  characteristic  appearance  to  one  picture  may  be  com- 
pletely absent  in  another,  and  that  the  same  cause  may  give  rise  to  the  most 
diverse  pictures.  An  idea  of  the  protean  character  of  this  disease  can  be 
obtained  by  combining  the  different  forms,  strengthening  (Fig.  34)  or  weak- 
ening the  individual  factors. 

There  are  other  signs  in  addition  to  those  that  have  been  mentioned,  but 
they  are  of  less  diagnostic  importance. 

(t)  Changes  in  the  blood  vessels,  in  the  form  of  accompanying  stripes 
(Fig.  33).  interruptions  of  the  column  of  blood,  and  spindle-shaped  pouch- 
ings   (Fig.  34). 

(C)    Detachments  of  the  retina  (Fig.  33)- 

('/)    Changes  in  the  vessels  of  the  chorioid  (Fig.  69)- 

(6)  Increase  of  the  signs  on  the  papilla  to  such  a  degree  that  it  is 
difficult  to  differentiate  it  from  a  choked  disk  with  patches  of  degeneration 
(Fig.  20).  The  diagnosis  is  finally  made  from  the  general  condition  (see 
page  82). 

It  still  remains  for  us  to  consider  the  details  of  these  signs,  referring  to 
the  various  pictures  and  the  accompanying  text.  There  is  one  point  that 
needs  to  be  brought  out  again,  the  behavior  of  the  vessels  in  albuminuric 
retinitis ;  the  arteries  are  much  underfilled,  while  the  veins,  on  the  contrai-}-, 
are  distended.  A  choked  disk  may  be  simulated  very  readily  b}'  an  increase 
of  the  symptoms  in  the  optic  nerve,  especially  when  there  is  at  the  same 
time  an  cedema  of  its  luatl,  the  more  so  as  choked  disk  sometimes  occurs 
together  with  these  patches  of  degeneration  in  the  retina.  r\  Michel  used  to 
say   humorously   that   he   knew  a   certain  high   oflicial   to   be   a    smart    fellow. 


134 

because  lu'  li:ul  in.'uic  a  tiimlv  I'fcoiriiitioii  of  the  alhiiiniiiuric  cliaractLT  of 
an  optic   neuritis   that   Irul   liccn   mistaken   elsewhere  for  a  choked  disk. 

AH  of  the  forms  which  were  mentioned  in  the  description  of  tlie  patliohigy 
of  the  white  spots  are  to  he  found  in  the  picture  of  alhuniinuric  ri'tiiiitis. 
We  see  the  deg-eneration  of  the  niTve  fibers  in  l''ig.  32,  the  fatty  (U'<reiieration 
of  the  supporting  fibers  in  tlie  stelhite  figure  in  Fig  30,  the  (hcjily  situated 
particles  of  fat  in  Fig.  31,  JUid  so  on.  To  what  the  enormous  changes  seen 
in  Fig.  34  are  due  cannot  be  told  with  certainty,  several  processes  take  part 
there  at  the  same  time,  degeneration,  fatty  degeneration,  calcification  and 
exudates.  All  of  these  things  are  to  he  referred  primarily  to  vascular  changes, 
■which  consist  essentially  of  hyaline  degeneration  of  the  small  and  smallest 
arteries  and  of  the  capillaries. 

Albuminuric  retinitis  occurs  in  all  forms  of  chronic  nephritis,  l)ut  is 
particularly  common  in  the  primary  interstitial  form,  Bright's  dise;ise,  and 
in  the  arteriosclerotic  form;  it  is  met  with  in  about  20  per  cent,  of  all  these 
cases.     Both  eyes  are  generally  affected. 

The  prognosis  is  very  grave.  The  probable  length  of  life  after  the  onset 
of  an  albuminuric  retinitis  is  at  most  two  or  three  years  in  90'/e  of  tlie  cases. 

The  prognosis  is  essentially  better  in  cases  due  to  the  nephritis  of  scarlet 
fever  and  of  pregnancy,  in  which,  when  the  acute  symptoms  are  not  caused 
by  an  exacerbation  of  a  chronic  nephritis,  complete  recovery  may  take  place, 
and  even  a  detached  retina  may  become  reattached. 

The  question  whether  an  abortion  is  justified  in  an  albuminuric  I'etinitis 
due  to  pregnancy,  is  answered  in  the  affirmative  by  most  writers,  esjjecially 
when  a  further  loss  of  the  vision  that  was  impaired  in  the  first  j)regnancy 
is  to  be  expected  in  the  second. 

The  albuminuria  of  eclampsia  can  give  rise  to  an  albumiiuiric  i-etinitis 
only  when  it  persists  after  delivery. 

The  amaurosis  oliserved  in  uraniia  and  eclampsia  is  of  cerebral  origin  and 
gives  no  signs  in  the   fundus. 

Retinitis  ciniudtit  needs  to  be  differentiated  from  albuminuric  retinitis. 
Spots  are  seen  in  this  disease,  some  isolated,  some  confluent,  which  appear 
quite  like  those  in  albuminuric  retinitis  and  differ  in  only  the  one  feature, 
that  they  surround  the  cloudy  region  of  the  macula  in  a  large,  transverse 
oval,  about  3  or  -i  P.  1).  across.  No  albumin  or  casts  are  to  be  found  in  the 
urine.     The  condition  is  one  of  sclerosis  of  the  delicate  vessels  of  the  macula. 

2.  The  characteristic  picture  of  albuminuric  retinitis  is  also  met  with  in 
diabetes  mellitus,  when  it  depends  on  the  same  pathological  condition. 

Fig.  35  furnishes  a  good  example.  A  stellate  figure  is  never  found  in 
the  macula  and  the  inflammatory  symptoms  on  the  papilla  are  usually  want- 
ing. Diabetic  retinitis  is  very  apt  to  occur  along  with  other  diabetic  dis- 
eases of  the  eye,  especially  with  iritis.  This  fact  is  of  a  certain  value  in 
making  the  differential  diagnosis  from  albuminuric  retinitis,  and  so  is  the 
one  that  hemorrhages   are  generally   more  abundant.      A  number  of  minute 


i;}5 

bright  points  can  be  seen  in  tlic  nmcuhi  by  the  direct  nR-tiiod.  WIrii  a 
central  scotoma  is  oljservtd  in  diabetes,  indicating  the  presence  of  an  axial 
neuritis,  it  is  very  small,  as  a  rule  al)out  5  degrees,  as  compared  with  the 
scotoma  in  all)uiiiinurie  retinitis,  which  generally  has  an  extent  of  over  10 
degrees. 

Diabetic  retinitis  is  usually  met  with  only  in  the  worst  cases  of  (iiahctes, 
hence  its  prognosis  is  pretty  bad;  half  of  the  patients,  on  the  average,  die 
in  the  course  of  the  next  two  or  three  years,  but  some  live  ten  or  fifteen  years 
with  this  affection. 

In  its  later  stages  diabetic  retinitis  frequently  tends  to  proliferations  of 
connective  tissue,  retinitis  {)roliferans  (Fig.  36). 

3.  Hctinitin  Icucoci/thtniiica. — In  addition  to  the  changes  described  on 
pages  102  and  119,  broadening  and  tortuosity  of  the  vessels,  yellow  red 
fundus,  and  hemorrhages,  we  see  in  leucocythannia  whitish  gray  patches  with 
bloody  margins,  which  vary  in  size  from  quite  small  to  as  large  as  the  papilla, 
situated  at  the  equator,  as  a  rule,  more  rarely  at  the  posterior  pole,  and  are 
sometimes  slightly  elevated.  »\t  tina's  an  optic  neuritis  and  such  brilliant 
fatty  spots  are  to  be  met  with  as  are  to  be  seen  in  an  albuminuric  retinitis. 
Leucocytha'mic  retinitis  is  almost  always  bilateral  and  accompanies  only  the 
splenic  and  tiie  myelogenic  forms  of  the  disease,  never  the  lymphatic. 

4.  White  spots  are  seldom  found  in  retinitis  unwmicu;  they  are  more  com- 
mon in  cancerous  cachexia,  when  they  appear  in  the  form  of  isolated,  silver 
white,  round,  oval,  or  striated  patches.  Usually  hemorrhages  also  are  pres- 
ent. The  blood  vessels  themselves  are  very  bright  and  consequently  have 
about  the  same  tone  of  color  as  the  rest  of  the  fundus,  as  the  result  of  wiiich 
they  do  not  stand  out  clearly,  but  seem  to  disappear  suddenly  as  they  leave 
the  papilla,  whicii  is  pale. 

5.  Bi'tinitis  ni/phiUtica  appears  in  i  forms:  1,  as  a  chorioretinitis  (see 
page  179);  2,  in  a  diffuse  form  (sec  page  149);  3,  as  a  neuroretinitis  (see 
page  7.5);  4,  in  the  form  that  is  pictured  in  Fig.  38. 

This  picture  resembles  that  of  a  partial  occlusion  of  the  central  artery. 
In  tills  particular  case  the  condition  seemed  to  be  an  occlusion  of  a  cilioretinal 
artery,  as  a  connection  with  the  true  retinal  vessels  could  not  be  discovered. 
A  striking  symptom  is  the  apparently  fibrinous  exudates  in  the  vicinity  of 
the  veins  and  arteries  elsewhere  in  the  fundus. 

This  case  was  one  of  syphilis  in  tiie  beginning  of  the  second  stage.  The 
sight  of  such  white  spots  must  always  arouse  the  suspicion  of  syphilis,  and 
the  diagnosis  is  then  made  positive  by   Wansermann's  reaction. 

The  prognosis  is  not  so  bad  when  proper  treatuR'nt  is  instituted,  yet  in 
this  particular  case  the  vision  remained  very  badly  impaired  on  account  of 
the  grave  injury  that  had  been  done  to  the  retina  by  the  occlusion  of  tiie 
artery,  which  manifested  itself  in  the  form  of  a  large  central  scotoma. 

Proliferations  of  connective  tissue  are  also  seen  to  take  place  as  a  con- 
sequence of  syphilis,  as  in  Fig.  37  (retinitis  proliferans). 


13(5 

6.  Retinitis  proliferans. — Tlic  essential  features  of  tliis  condition  have 
already'   been  described   on   pa^e    I'ii),   under   tlie   caption    of   connective   tissue. 

7.  In  cases  of  choked  disk,  especially  after  tlie  condition  lias  lasted  a 
long  time,  j'ellowish  white  spots  may  sometimes  be  found  without  any  true 
retinitis.  These  are  usually  caused  by  patches  of  degeneration  in  the  layer 
of  nerve  fibers  (see  page  80).  Tlie  knowledge  of  this  fact  is  very  valuable 
in  the  differential  diagnosis  of  this  condition  from  the  so-called  alliuininuric 
choked  disk  (sec  page  79). 


PLATE  XVII 

Fig.  30.     Retinitis  Albuminurica 
Fig.  31.     Retinitis  Albuminurica 


Fig.  30.     Retinitis  Albuminurica 

(Sue  i)uf.L.  i;5;j) 

TIic  fundus  is  wry  darkly  |ili;nuiilc(l,  a  piirily  incidental  condition,  and 
distinct  reflex  liands  can  lie  seen  aloiiir  the  vessels.  The  papilla  is  normal. 
AVliite  strijc,  that  form  an  incomplete  star,  arc  to  be  seen  in  the  ri'gion  of  the 
niacida.  Tiie  center  of  the  star  is  niarketi  by  a  heap  of  pigment.  A  number 
of  large  and  an  enormous  number  of  small  spot.s  are  visible  in  the  vicinity 
of  the  star. 

No  hemorrhages  and  no  distinct  changes  in  the  vessels  can  be  seen.  The 
wliite  spots  are  usually  caused  by  fatt}'  degeneration  (see  page  I'JO). 

The  stellate  figure  is  a  very  ])rominent  and  suggestive  symj)tom  of  albu- 
minuric retinitis,  but  it  is  by  no  means  always  present.  Indeed,  it  is  not 
pathognomonic  of  this  tliscase,  for  it  is  met  with  in  others,  such  as  tumor  of 
the  brain,  and  syphilis,  although  much   hss  conmionly. 

.Albuminuric  retinitis  occurs  chiefly  in  connection  "itli  chronic  interstitial 
ne])hritis,  and  the  patients  usually  die  Avithin  2  or  .'5  years. 


Fig.  31.     Retinitis  Albuminurica 

(See  page  Ititi) 

This  is  bv  far  the  more  common  form  of  albumiiuiric  retinitis.  The 
changes  mav  indeed  be  much  more  tri\ial  and  lacking  in  character  than  the 
ones  depicted;  one  or  two  white  spots,  with  or  without  hemon-hages,  may 
sometimes  be  all  the  basis  on  which  to  make  the  diagnosis. 

A  large  number  of  roundish,  yellowish  white  spots  are  to  be  seen  below 
the  upper  temporal  artery,  following  fairly  well  along  its  course.  A  little 
below  these  are  a  number  of  spots  of  blood,  which  lie  in  the  deej)er  layers  of 
the  retina,  as  shown  by  their  roundish  form.  The  entire  region  of  the  macula 
is  covered  by  a  slight  veil,  which  completely  hides  the  markings  of  the 
chorioid  that  are  to  be  seen  distinctly  in  its  temporal  portion.  'I'he  large 
dark  spot  to  be  seen  at  the  lower  margin  of  the  picture  is  to  be  looked  upon 
as  congenital  (na;vus),  because  of  the  absence  of  signs  of  inllammation  and 
degeneration  in  its  vicinity. 


138 


Tab.  17. 


Fitr.  30. 


Fig.  31. 


PLATE  XVIII 

Fig.  32. — Neuroretinitis  Albuminurica 

Fig.    33.     Neuroretinitis   Albuminurica   Gravidarum   with 
Detachment  of  the  Retina 


Fig.  32.     Neuroretinitis  Albuminurica 

(Sec  page  i;j.'J) 

The  morbid  cliaii^'cs  in  tliis  ])icturL'  arc  coiiliiird  wliollv  to  the  papilla 
and  its  immediate  vicinity.  Tlic  papilla  is  very  red,  and  is  surroundrd  hy  a 
white  ring,  about  a  papiliai-y  diameter  broad,  which  shows  in  certain  places 
a  distinct,  radiating  striation.  This  ma}'  simulate,  to  the  passing  glance, 
a  resemblance  to  lueduilated  neryi'  fibers,  but  the  clianges  in  tile  vessels  and 
the  hemorrhages  imiiudiately  correct  such  an  error.  Tiie  striations  sliow  that 
the  lesion  lies  in  the  layer  of  nerve  fibers  whicli  radiates  from  the  papilla. 
The  disproportion  in  the  degree  of  fullness  of  the  artei-ies  ;ind  of  the  veins 
indicates  a  serious  inflannnation  of  tlu'  iiead  of  tiie  optic  nerve  that  has  caused 
a  compression  of  tiie  vessels.  If  the  head  of  the  optic  nerve  were  greatly 
.swollen  the  picture  would  closely  resemble  one  of  choked  disk   (see  page  133). 


Fig.   33.     Neuroretinitis   Albuminurica   Gravidarum  with 
Detachment  of  the  Retina 

(  See  page  1 3.'i ) 

This  picture  has  a  cei-taiii  i-esemblaiice  to  the  preceding,  yet  no  hemor- 
rhages are  present,  and  the  form  of  the  change  is  not  the  same.  There  is  a 
disproportion  in  the  degree  of  fullness  of  the  arteries  and  of  the  veins,  just 
as  in  the  preceding  case.  The  white  stripes  that  accompany  the  vessels  may 
be  ascribed  to  extravasation,  or  distentinn  of   I  he  })erivasculai'  lymj)h   spaces. 

The  picture  was  complicated  in  this  case  by  the  jjresence  of  a  large  de- 
tachment of  the  retina. 

The  prognosis,  as  regards  both  the  reattachment  of  the  retina  and  the  life 
of  the  patient,  is  materially  better  when  the  condition  is  due  to  the  nephritis 
of  ])regnancy  than  when  it  is  occasioned  by  other  causes  (see  page  134). 


140 


lab.  IH. 


Fig.  32. 


If'.  33. 


PLATE  XIX 

Fig.  34. — Very  Severe  Neuroretinitis  Albuminurica 
Fig.  35.— Neuroretinitis  Diabetica 


Fig.  34.     Very  Severe  Neuroretinitis  Albuminurica 

(See  page  138) 

The  entire  vicinity  of  the  optic  nerve,  for  a  distance  of  from  two  to  five 
pupilhiry  diameters,  is  transformed  into  a  chalky  white  hiyer  which  has, 
here  and  there,  a  r?ddish  tone.  A  beautiful  stellate  figure  is  to  be  seen  at  the 
macula.     The  arteries  are  small,  the  veins  dilated   (see  page  133). 

This  patient  died  four  weeks  after  tlie  picture  was  taken  (see  page  IS-i). 


Fig.  35.     Neuroretinitis  Diabetica 

(See  page  IS-t) 

Diabetes  can  produce  a  picture  that  is  quite  similar  to  that  caused  by 
nephritis  because  the  anatomical  basis  of  the  changes  is  the  same.  Tlie  papilla 
is  very  red,  its  margins  slightly  hazy,  and  there  is  a  little  oedema  in  its  vicinity. 
Numerous  little  spots  of  hemorrhage  can  he  seen  in  the  upper  part  of  the 
picture,  one  of  which  lies  so  close  to  a  vessel  of  the  retina  that  the  latter  must 
be  supposed  to  be  thrombosed. 

The  lower  part  of  the  picture  exhibits  many  yellowish  white  spots,  some 
discrete,  others  blended  into  large  patches.  The  color  of  these  varies  with 
their  age,  the  younger  ones  are  the  whiter.  They  become  reddened  and  lose 
their  sharp  contour  in  the  stage  of  absorption. 


142 


Tab.  19. 


Fig.  34. 


hig.  35. 


PLATE  XX 

Fig.  36.     Retinitis  Proliferans  in  Diabetes 
Fig.  37.     Retinitis  Proliferans  in  Syphilis 


Fig.  36.     Retinitis  Proliferans  in  Diabetes 

(Sec  pages   I'Jit  and   i;J4  ) 

Retinitis  j)rolitVraiis  not  rarrlv  is  tlii'  i-esult  of  a  diabetic  retinitis.  TIio 
masses  of  connective  tissue  follow  the  vessels,  from  tlie  adventitial  slieaths  of 
which  they  are  accustomed  to  orifrinatc.  Some  of  the  vessels  of  the  retina 
have  disappeared,  some  show  varicosities  (see  page  102). 

Hemorrhages  and  wliite  spots  complete  tiie  picture. 


Fig.  .37.     Retinitis  Proliferans  in  Syphilis 

(See  pages  129  and  liiS) 

The  papilla  has  a  peculiar,  cold,  red  tone,  which  is  characteristic  of  an 
optic  neuritis  that  is  undergoing  involution. 

Along  the  upper  temporal  ai-terv  and  vein  are  cordlike  l)\nidles  of  con- 
nective tissue,  which  originate  from  the  sheaths  of  the  vessels,  just  as  in  the 
preceding  case. 

This  patient  presented  the  symptoms  of  syphilis  in  the  secondary  stage; 
Wassermann's  reaction  was  positive. 

Otherwise  the  fundus  is  normal,  but  atrojihic  spots  may  sometimes  be 
seen  in  the  periphery. 


144 


Tab.  20. 


Fm.37. 


PLATE  XXI 

Fig.  38.     Retinitis  Luetica 
Fig.  39.    The  Same  Case  Six  Weeks  Later 


Fig.  38.     Retinitis  Luetica 

(Set'  page  i;j5) 

Attention  is  called  chiefl}'  to  an  ojiacity  whicli  passes  transversely  across 
the  field  of  vision,  is  about  one  pa{)illary  diaiiieter  broad,  and  is  to  be  ascribed 
to  an  occlusion  of  a  cilioretinal  artery  whicii  supplies  tlie  region  of  the  macula. 
The  vision  was  greatly  iiiijjaired  by  tlie  presence  of  a  central  scotoma.  The 
papilla  is  normal.  Large  exudates,  that  look  like  bits  of  cotton,  can  be  seen 
on  some  of  the  vessels,  especially  the  veins  (see  page  135). 

These  symptoms  appeared  about  six  months  after  syphilis  had  been  con- 
tracted. 

Fig.  39.     The  Same  Case  Six  Weeks  Later 

The  central  opacity  has  subsided  considerably.  The  vision  is  still  badly 
impaired  by  the  persistent  central  scotoma.  A  coronula,  such  as  is  often  to 
be  seen  after  occlusion  of  the  central  artery,  is  visible  in  the  macula.  The 
exudate  has  undergone  involution  to  a  considerable  extent. 

Two  months  later  nothing  was  visible  except  the  coronula  and  the  oblitera- 
tion of  the  vessel  lying  farthest  to  tlie  left. 


146 


Tab.  21. 


Fig;.  38. 


Fig.  39. 


PLATE  XXII 

Fig.  40.     Sympathetic  Optic  Neuritis  and  Chorioiditis 

Fig.  41.     Colloid  Deposits  on  the  Vitreous  Lamella  of  the 

Chorioid 


Fig.  40.     Sympathetic  Optic  Neuritis  and  Chorioiditis 

(See  page   127) 

Tills  picture  was  taken  from  tlie  riylit  eye  of  a  man,  20  years  okl,  whose 
left  eye  had  been  lost  as  the  result  of  an  injury  with  subsetjuent  iridocyclitis. 

About  two  iiiontlis  after  thr  injury  soiiir  deposits  appeared  on  Desce- 
vwt's  iiieiiibrane  in  the  other  eye,  together  with  a  slight  iritis.  The  vitreous 
was  filled  with  minute,  diffuse  ojjacities,  yet  the  fundus  could  be  seen  very 
well.  Vision  was  reduced  to  Va  the  normal,  the  visual  field  was  normal,  and 
no  central  scotoma  could  be  demonstrated.  The  papilla  was  very  red,  its 
upper  margins  indistinct,  the  veins  were  distended,  the  arteries  scarcely 
changed,  and  no  distinct  <edoma  was  visible  in  the  retina.  Far  in  the  periphery, 
moved  inward  a  little  in  the  picture,  were  several  sharply  defined,  yellowish 
spots.  The  color  about  them  was  slightly  brownish,  but  there  was  no  true 
pigmented  edge,  and  no  lump  of  pigment.  Such  spots  ai'e  thought  to  be  retinal 
by  many  authors,  yet  the  entire  character  of  the  disease  indicates  that  they 
are  situated  in  the  chorioid.  The  patient  was  under  observation  for  about 
three  years,  and  the  spots  did  not  change  during  this  time. 


Fig.  41.     Colloid  Deposits  on  the  Vitreous  Lamella  of  the 

Chorioid 
(See   page    127) 

This  picture  was  taken  from  the  eye  of  an  old  woman.  The  fundus  is  nor- 
mal, of  the  tcsselated  type.  The  optic  nerve  and  the  vessels  are  likewise  nor- 
mal. In  the  region  of  the  macula,  and  in  the  vicinity  of  the  papilla  can  be 
seen  a  number  of  roundish  spots  with  a  rather  strong  pigmentation  about 
them.  The  spots  near  the  papilla  are  brilliantly  white,  while  those  in  the 
macula  have  a  faded,  reddish  gray  appearance.  This  reddish  gray  is  not 
the  usual  color,  which  is  commonly  the  same  as  that  of  the  brighter  parts  lying 
near  the  papilla.  These  so-called  colloid  deposits  are  thickenings  of  the 
lamina  vitrea  which  destroy  the  pigment  epithelium  at  the  places  where  they 
occur.     As  a  rule  the  vision  is  very  little  disturbed  (see  page  127). 


148 


Tab.  33. 


Fig.  40. 


ii'.  n 


149 


III.    DIFFUSE  OPACITY  OF  THE  RETINA 

(a)  ■mthout  yrcai  differences  of  level, 

mav  be  due  to  various  anatomical  conditions,  the  same  as  the  white  spots. 

1.  The  commonest  cause  is  oedema.  Tiie  portion  of  the  retina  afFccted 
appears  gray,  or  reddish  gray,  and  the  markings  of  tlie  chorioid  beneath  it 
can  be  seen  very  indistinctly.  The  latter  characteristic  is  particularly  evi- 
dent when  the  oedema  is  found  in  a  more  or  less  albinotic  fundus  (see  Fig.  22). 

When,  on  the  other  hand,  the  color  of  the  fundus  is  uniform,  this  is  a 
A'ery  deceptive  sign  (see  Figs.  18  and  31i  center).  The  vessels  of  the  retina 
are  simply  covered  by  a  thin  veil,  or  tiu  v  are  embedded,  so  that  they  appear 
to  be  broken  in  places,  according  to  tjie  degree  of  the  cedema. 

(Edema  is  met  with  in  almost  all  severe  diseases  of  the  retina,  for  exam- 
ple, in  nearly  all  the  cases  that  have  been  described  in  which  white  spots  were 
to  be  observed,  yet  it  is  commonly  cast  into  the  background  by  the  other, 
more  prominent  changes  in  the  eye  (Fig.  31). 

(Edema  is  also  met  with  in  circumscribed  inflammations  of  the  chorioid 
(see  page  125).  When  such  an  oedema  occurs  in  the  region  of  the  macula 
alone  it  is  usually  very  difficult  to  recognize,  and  yet  we  are  guided  pretty 
often  to  this  diagnosis  by  a  fairly  rapid,  great  impairment  of  the  vision. 
The  pupil  must  then  be  dilated  to  admit  of  a  more  accurate  examination, 
and  when  the  diagnosis  is  still  not  positive  the  test  for  central  blue  blindness 
should  be  made.     This  is  done  best  by  Haitz'  method. 

ffidema  plays  a  very  important  part  in  the  so-called  refinifii  diffusa.  It 
is,  in  most  of  these  cases,  a  local  phenomenon  of  diffuse  neuroretinitis,  and 
appears  as  a  sequel  to  any  optic  neuritis.  It  is  particularly  well  marked  in 
syphilitic  disease  of  the  head  of  tlie  optic  nerve.  To  a  less  marked  degree 
such  an  oedema  can  be  seen  in  Fig.  18-  in  which  it  surrounds  the  reddened, 
indistinct  papilla  like  a  ring.  The  diagnostic  importance  of  tliis  oedema  in 
determining  whether  a  condition  is  optic  neuritis  or  pseudoneuritis  has  been 
pointed  out  on  page  71. 

Besides  the  gray  color  wc  see  that  the  vessels  of  the  retina  appear  to  be 
slightly,  but  distinctly  veiled.  The  obliteration  of  the  markings  of  the  cho- 
rioid is  not  evident  because  the  fundus  is  strongly  pigmented.  In  other  cases 
the  oedema  may  be  considerably  more  marked,  and  may  have  even  a  striated 
appearance  when  it  lies  chiefly  in  the  layer  of  nerve  fibers.  This  form  is 
usually  of  a  syphilitic  nature.  Hemorrhages  and  white  spots  are  considerably 
less  common  then  than  wlicn  it  is  due  to  otiicr  diseases. 

Although  syphilis  is  the  most  coniinon  and  the  most  important  cause  of 


150 

peripaju'lhirv  a>dcma,  it  is  not  tlif  only  one.  'riii^  affictions  of  tlii'  optic  iutvl", 
due  to  diseases  of  tlie  ear,  are  verv  imi)ortant  (see  page  77).  In  these  cases 
tlie  oedema  may  precede  the  changes  in  the  optic  nerve,  and  may  he  at  times 
tl»e  only  symptom  present.  It  seems  to  lie  in  the  deeper  layers  of  the  retina, 
as  striations  are  almost  never  seen. 

It  inav  also  he  ohserved  in  choked  disk,  especially  in  the  alhuiiiiniiric  va- 
riety, hut  hemorrhages  and  white  spots  are  seldom  wanting  in  such  cases. 

2.  Another,  very  much  rarer,  form  of  diffuse  o])acity  of  the  retina  is  the 
diffuse  infiltration  with  white  blood  corpuscles,  an  outspoken  inflammation. 
This  is  characterized  hy  the  very  marked  sheathing  of  the  vessels  of  the  retina 
shown  in  Fig.  42,  which  is  to  be  ascribed  to  a  distention  of  the  adventitial 
sheaths  of  the  vessels  with  white  blood  corpuscles.  This  form  is  likewise  met 
with  in  syphilis,  and  sometimes  in  leucocythaMiiia.  Considerable  accumula- 
tions of  leucocytes  in  circumscribed  places  make  themselves  evident  as  white 
spots. 

3.  A  necrosis  of  the  inner  layers  of  the  retina  in  connection  with  recur- 
rent oedema  (Figs.  44  and  45)  underlies  the  opacity  of  the  retina  in  occlu- 
sion of  the  centred  arteri/.  In  these  cases  the  demonstration  of  the  cherry 
red  spot  (see  also  page  72),  which  is  sometimes  surrounded  by  a  particu- 
larly cloudy  halo,  hut  usually  lies  in  its  opaejue  surroundings  without  such  a 
special  border,  is  of  diagnostic  value.  The  opacity  itself  is  brighter  in  these 
cases  than  it  is  in  purely  infiannnatory  oedema,  and  sometimes  it  is  perfectly 
white.  The  arteries  are  usually,  though  by  no  means  always,  invisible,  or 
considerably  diminished  in  size.  The  eroded  place  in  the  vessel  itself  can  be 
seen  in  many  cases  as  a  w-hite  spot,  as  in  Fig.  45  on  the  papilla.  Pulsation 
is  absent  when  pressure  is  made  on  the  eyeball  (see  page  107).  The  opacity 
gradually  retrogresses  (compare  Fig.  45  with  Fig.  44)  until  finally  the 
normal  color  of  the  fundus  returns,  with  a  uniform  whiteness  of  the  papilla 
and  an  extreme  contraction  of  the  arteries,  but  intermixed  with  a  gentle  dark 
gray  tone,  due  to  a  migration  of  pigment  cells  into  the  atrophic  retina  ( Fig. 
16).  This  migration  of  pigment  is  particularly  distinct  in  the  region  of 
the  macula,  where  it  takes  part  in  the  formation  of  the  coronula  (see  page 
127). 

The  occlusion  sets  in  with  sudden  amaurosis,  which  commonly  is  irre- 
parable. 

Sometimes  it  is  not  the  entire  trunk  of  the  artery  that  becomes  occluded, 
but  one  or  more  of  its  branches  (see  Fig.  38,  P'lying  "o  attention  to  the 
white  spots).  Then  the  amaurosis  is  not  total,  but  affects  only  certain  por- 
tions of  the  field  of  vision. 

It  also  may  happen  that  the  trunk  of  the  artery  is  occluded  behind  the 
point  where  certain  branches  are  given  off.  The  region  supplied  by  these 
branches  is  then  seen  to  be  of  a  normal  red  color,  while  the  rest  of  the  retina 
is  opaque.     The  vision  appertaining  to  this  place  is  j)reserved. 

4.   The   opacity   in   cases   of  conmiotio   retina'   (Fig.   43)    if^   to  be   looked 


151 

upon  as  due  to  x-asomotor  disturlxincc  -idfh  transudation.  The  opacity  may- 
have  a  close  resemblance  to  the  one  just  described.  It  is  usu.iily  i'ounil  near 
the  macula  or  the  papilla.  The  condition  of  the  vessels,  which  are  normal 
or  dilated,  and  the  other  signs  of  traumatism  frequently  to  he  observed,  such 
as  hemorrhages  and  ruptures  of  the  chorioid,  taken  together  with  the  his- 
tory, generally  enable  a  ditt'erential  diagnosis  to  be  made  from  other  forms  of 
opacity.  Usually  the  vision  is  harmed  little  if  at  all.  The  transudate  j)asses 
away  in  a  few  days. 

5.  Another  cause  of  a  diffuse  opacity  is  the  flat  dctachnu-nt  of  the  retina 
(Fig.  46).  The  wt)rd  "Hat"  must  be  emphasized  in  this  c(mnection,  because 
the  chief  and  most  striking  symptom  in  the  eye  when  the  detachment  is  gib- 
bous is  the  difference  in  level. 

The  color  of  the  detached  portion  is  gray,  sometimes  gray  green  or  gray 
blue.  The  detachment  may  be  total  (Fig.  46).  '>r  ])arti.d  (Fig.  47).  P'lr- 
ticular  attention  is  to  be  paid  in  the  differential  diagnosis  to  the  white 
cords,  in  the  vicinity  of  which  the  vessels  of  the  retina  often  show  abnormal 
bends.     These  are  the  apices  of  the  folds  formed  in  the  retina. 

A  very  valuable  symj)tom  is  the  absence  of  the  markings  of  the  chorioid  in 
the  detached  portion,  which  are  visible  elsewhere.  The  vessels  of  the  retina 
throughout  the  same  area  are  vei-y  dark  and  have  no  reflex. 

The  local  elevation  of  tlie  retina  may  frequently  be  perceived  by  parallactic 
displacement  and  by  determination  of  the  refraction. 

In  cases  of  total  detachment  of  the  retina  the  loss  of  vision  is  very  great; 
when  the  detachment  is  partial  the  loss  is  greater  or  less,  according  to  the 
position  it  occupies.  The  field  of  vision  usually  exhibits  a  contraction  that 
corresponds  to  the  detached  part. 

Ordinarily  the  detachment  begins  in  the  upper  part  of  the  retina  and 
causes  a  defect  in  the  lower  part  of  the  field  of  vision,  so  that  when  the  pa- 
tient looks  at  a  person  the  latter  may  seem  to  have  no  legs ;  later  it  moves 
downward  and  causes  a  defect  in  the  upper  part  of  the  field,  so  that  the  per- 
son looked  at  may  seem  to  have  no  head. 

When  a  detachment  connnences  the  patients  complain  of  siihjective  sensa- 
tions of  light,  the  so-called  photopsias,  which  are  described  as  scintillations, 
flashes,  balls  of  fire,  sparks,  or  circles.  Objects  also  appear  to  be  distorted, 
bent,  or  jagged  ( metamorphojisia),  and  sometimes  they  seem  to  be  of  a  pro- 
nounced green.  The  detachetl  places  are  blind  to  blue,  i.e.,  blue  is  perceived 
by  them  as  green  or  gray,  and  the  patients  suffer  from  hcmeralopia,  .i.e.,  their 
vision  becomes  disproportionately  bad  as  the  light  is  reduced. 

The  etiology  varies.     It  may  be 

1,  purely  ocular,  or  local,  as  when  the  detachment  is  caused  by  an  injury, 
either  a  perforating  wound,  or  a  contusion,  hemorrhages,  tumors,  or  a  high 
degree  of  myopia ; 

2,  general,  as  when  due  to  nephritis,  arteriosclerosis,  or  syphilis.  In 
many  cases  the  diagnosis  of  these  diseases  as  the  cause  can  be  determined  from 


152 

other  ocular  signs,  as  from  sck'roscd  vessels,  whiti.'  spots,  or  black  spots,  but 
in  others  the  differentiation  must  be  made  by  means  of  a  general  examination. 
Ai'tcriosclerosis  is  the  etiological  factor  in  l-'ig.  47,  as  sliown  by  the  sclerotic 
vessels  in  the  vicinity  of  the  pajiilla. 

(b)    Diffuse  Opuiitii  of  the  UctiiKi  xdtli  Mdrkcd  D'ltfcrcncca  of  Level. 

A  difference  of  level  is  indicated  wliiii  some  parts  of  tiie  fundus  are  plainly 
visible  during  an  ophthalmoscopic  exaiiiinatii)n,  while  others  arc  indistinct. 
Detachment  of  the  retina  shares  this  symptom  with  quite  a  number  of  other 
diseases,  sucii  as  a  great  amount  of  (I'deiiia,  and  opacities  in  the  vitreous,  but 
it  is  cliaracteristic  of  detachiiunt  of  I  lie  lutina  wluii  it  disappears  as  soon 
as  the  observer  makers  his  examination  from  a  greater  distance  than  usual, 
and  the  portions  that  were  indistinct  become  clear,  while  those  which  were 
clear  at  first  become  indistinct. 

The  reason  of  this  phenomenon  is  that  the  detached  portions  of  the 
retina  lie  farther  forward  than  the  rest  and  conse(|uently  have  a  different 
refraction.  In  most  cases  the  diagnosis  of  a  detachment  of  the  retina  can  be 
made  more  conveniently  by  simply  casting  light  into  the  eye  with  the  mirror 
of  the  ophthalmoscope  than  by  an  examination  of  either  the  inverted,  or  the 
upright  image,  as  the  detached  portions  then  look  much  less  red  than  the 
others. 

When  the  detached  retina  lies  very  far  forward  it  may  sometimes  be  seen 
by  oblifjue  illumination. 

Figures  48  and  49  therefore  do  not  give  pictures  tliat  are  true  to  nature 
of  a  detachment  of  the  retina,  they  are,  rather,  composite  pictures  which 
assume  the  ciianges  to  be  made  in  the  position  of  the  examiner. 

Figures  48.  49.  and  50  exhibit  types  of  such  a  detachment. 

1.  Fig.  48  shows  a  (jibbous  detaehment  caused  hi/  an  exudate.  The  arch- 
ing of  the  retina  can  be  seen,  in  addition  to  its  changed  color  and  the  forma- 
tion of  folds.  The  papilla  has  a  slight  haziness,  which  might  perhaps  cause  it 
to  be  mistaken  for  an  optic  neuritis  (see  page  72). 

A  distinct  movement  of  the  bulla  back  and  forth  ma}-  be  seen  during 
movements  of  the  eye. 

2.  Fig.  49  shows,  in  contrast  to  the  above,  a  detachment  of  the  retina 
caused  hi/  a  tumor  of  the  chorioid.  Its  margins  are  sharply  defined.  No 
movement  can  be  detected;  on  the  contrary,  the  detacjiment  gives  the  impres- 
sion of  a  solid,  firm  mass,  which  is  increased  by  the  fact  that  a  reddish  shim- 
mering from  the  tumor  beneath  the  detached  retina  can  be  seen  in  certain 
places. 

The  difference  is  not  so  distinct  as  it  is  in  these  pictures  in  many  cases, 
and  then  the  differential  diagnosis  is  best  undertaken  with  the  aid  of  Hert- 
zell's  lamp,  which,  when  introduced  into  the  mouth,  transilluminates  the  globe 
from  behind.  A  dark  spot  is  to  be  seen  when  a  tumor  is  present,  while  a 
serous  eirusion  allows  the  light  to  pass  through  freely.  This  method  is  par- 
ticularly useful  when  tumors  are  situated  in  the  posterior  segment  of  the  eye- 


153 

ball,  while  for  those  in  the  antei-ior  seginent  better  service  is  obtained   from 
Sach's  lamp,  wiiich  transilluniiiiiites  the  eyeball  laterally. 

3.  Fig.  50  shows  a  gliamu  of  the  retina.  Tlie  diagnosis  rests  chiefly  on 
the  facts  that  an  embedding  of  the  vessels  of  tiie  retina  can  be  seen  in  the 
tumor,  and  that  the  patient  is  young. 

In  a  total,  funnel-shaped  detachment  of  tlic  retina  no  picture  of  tlie  fundus 
can  be  obtained,  as  can  readily  lie  understood  if  we  look  at  P'ig.   R.      If  the 
lens  is  transparent  the  detached  retina  can  often  be  seen  by  ol)ii(iue  illumina- 
tion, and  the  rounded  protrusion  can  sometimes  be  seen  by 
simj)ly  throwinti;  light  into  the  eye  with  tlie  mirror  of  the 
ophthalmoscope,  but  when  these  means  fail  a  conclusion  as 
to  the  condition  of  tlie  retina  can  bo  drawn  from  the  pro- 
jection, as  a  large  hemorrhage  into  the  vitreous  may  pro- 
duce a  similar  picture.     Loss,  or  limitation  of  the  projec- 
tion is   indicative  of  detachment,   correct   projection  of   a  y.^^    j^ 
hemorrhage. 

Concerning  the  Prognosis  as  to  Life  of  Diseases  of  the  Retina 

and  Chorioid 

Geiss  lias  drawn  conclusions,  of  which  the  following  is  an  abstract. 

I    Arteries  of  the  Retina. 

1.  Marked  Arteriosclerosis  oi  the  Retinal   Vessels. 

All  of  the  patients  observed,  to  the  number  of  IT.  ranging  in  age  from 
40  to  7()  years,  suffered  from  an  attack  of  apoplexy  within  4  years  at  the 
most. 

2.  Sudden  Occlusion  of  the  Central  Arter//. 

(a)  Seventeen  patients,  between  40  and  70  years  of  age.  with  arterio- 
sclerosis, but  without  heart  elisease.  Of  these  14  had  an  attack  of  apoplexy 
within  2  years,  the  other  3  died  from  arteriosclerosis  in  from  1  l/o  to  7  years. 

(b)  Si::  patients,  between  40  and  70  years  of  age.  with  heart  disease. 
One  died  of  apoplexy  3  years  later,  4  from  heart  disease  within  2  or  3  years, 
and  one  was  still  alive  at  the  end  of  4  years. 

(c)  Nine  patients,  39  years  or  less  of  age,  with  heart  disease.  Prog- 
nosis not  so  liad. 

3.  Syphilitic  diseases  of  the  retina  do  not  have  the  same  bad  prognosis 
as  arteriosclerotic  changes. 

II.  Veins  of  the  Retina. 

Thrombosis  of  tlie  veins  of  the  retina  has  not  the  bad  prognosis  of  the  dis- 
eases of  the  arteries.  It  is  a  purely  local  disease  in  .50%  of  the  cases,  and  in 
only  50%  is  a  forerunner  of  a  sclerosis  of  the  cerebral  vessels,  wiiich  may  not 
make  itself  manifest  until  a  long  time  afterward. 


III.  Vessels  of  the  Chorioid. 

No  coiu-lusioiis  ;i.s  to  tile  coiulitioii  of  tlic  vessels  in  the  brain  can  he  drawn 
from  sclerosis  of  those  in  the  chorioid. 

I\ .  Retinal  Hemorrhages 

in  arteriosclerosis,  diabetes,  and  chronic  ne[)hritis  are,  as  a  rule,  harbinfrcrs 
of  hemorrhages  into  the  brain,  which  yet  may  not  occur  until  after  the  lapse 
of  years. 

Hemorrhag'es  into  the  vitreous  in  young  persons,  isolated  hemorrhages 
in  the  macula,  and  the  retinal  hemorrhages  caused  by  syphilis  do  not  partake 
of  this  bad  j)rognosis. 

V.  Retinitis  Albuminurica. 

Of  .'{«  patiints,  '2!)  died  within  1  year:  -i  died  in  from  1  to  2  years;  2  died 
in  from  2  to  4^  yeai's. 

Three  jiatients  with  retinitis  albuminurica  gravidarum   recovered. 

VI.  Retinitis  Diabetica. 

Diabetic  retinitis  has  a  different  prognosis  from  the  isolated  hemorrhages 
in  the  retina  met  with  in  diabetes,  which  are  to  be  considered  as  precursors 
of  cerebral  apoplexy.  Apoplexy  supervened  in  only  ^  of  the  cases.  Half 
of  the  patients  died  within  2  or  3  years. 


PLATE  XXIII 

Fig.  42.    Retinitis  Luetica 
Fig.  43.    Commotio  Retinae,  or  Berlin's  Opacity 


Fig.  42.     Retinitis  Luetica 

(Sec  pago  150) 

Primary  sypliilitic  retinitis,  wlieii  not  a  local  plicnomenon  of  a  ncuro- 
rctiiiitis,  is  a  fairly  rare  disease  in  comparison  with  the  secondary  syphilitic 
diseases  of  the  retina  due  to  an  atteetion  of  the  capillaries  of  the  choiioid. 
In  the  case  presented  here  the  papilla  is  comparatively  little  involved;  its 
color  is  almost  normal,  its  margins  are  fairly  distinct,  Init  the  vessels  that 
lie  upon  "it  exhibit  a  distinct  obscuration  and  sheathing.  The  retina,  on 
the  contrary,  is  cloudy  over  a  large  extent,  and  only  a  few  of  the  vessels 
of  the  chorioid  can  be  seen  through  the  opacity.  The  vessels  of  the  retina 
look  ha/y  throughout  the  entire  extent  of  the  opacity  and  are  y)artly  sheathed 
everywhere.  \o  hemorrhages  are  visible;  only  a  few,  striated,  wiiitish  spots 
can  be  seen.  In  a  similar  case,  which  was  studied  pathologically  by  Buck, 
partial  and  circular  inflammations  of  the  adventitia  and  intima,  together 
with  obliterations  of  the  capillaries,  were  found  to  he  tlie  cause  of  the 
trouble. 

Fig.  43.    Commotio  Retinae,  or  Berlin's  Opacity 

(See  page    l.jO) 

This  opacity  received  its  name  not  from  the  city,  but  from  the  ophthal- 
mologist Berlin,  who  was  the  first  to  describe  the  condition,  and  to  differ- 
entiate it  froin  detachment  of  the  retina.  The  condition  depicted  here  was 
produced  by  the  blow  of  a  ball  against  the  eye  of  a  boy  12  years  old:  tiie 
picture  was  taken  a  few  hours  after  the  injury. 

The  papilla  is  much  reddened,  its  margins  are  slightly  hazy,  enough  so 
as  to.be  suggestive  of  a  commencing  optic  neuritis,  but  the  vessels,  especially 
the  veins,  are  normal.  A  light  gray  ring,  with  a  rather  darker  center,  can 
be  seen  in  the  region  of  the  niacida.  Such  a  lesion  can  be  mistaken  for  a 
connnencing  detachment  of  the  retina  when  the  vessels  do  not  run  smoothly 
over  it  and  there  is  any  sign  of  a  fold.  The  changes,  which  caused  only  a 
slight  impairment  of  the  vision,  disappeared  completely  after  a  few  days 
(.sec  page  72). 

The  color  of  the  opacity  may  be  more  intense  than  it  is  in  this  case,  it 
may  incline  more  to  yellow,  or  to  white,  and  it  need  not  be  situated  exactly 
in  the  region  of  the  macula. 

The  nature  of  this  change  has  not  ^et  been  learned. 


156 


Tab.  23. 


Fig.  42. 


Fig.  43. 


PLATE  XXIV 

Fig.   44.     Sudden   Total    Occlusion   of  the   Central   Artery,    the 

So-called  Embolism 

Fig.  45.    Occlusion  of  the  Central  Artery  in  a  Later  Stage 


Fig.   44.     Sudden   Total    Occlusion    of   the    Central    Artery,    the 

So-called  Embolism 

(See   l)ayt'    150) 

Occlusion  is  caused  by  n  true  einhoius  only  in  extremely  rare  cases,  and  is 
usually  due  to  a  slowly  developincr,  hut  sudtlenly  becoming  total,  closure  of 
the  lumen  of  the  artery  by  a  proliferation  of  the  intima,  endarteritis  pro- 
liferans. 

The  papilla  is  very  red,  its  margins  completely  hidden,  the  arteries  can 
scarcely  lie  seen.  A  large  area  of  the  fundus,  about  6  V.  D.  across  and 
including  both  the  papilla  and  the  macula,  is  whitish  gray  and  opaque.  The 
well-known  cherry  red  spot  can  be  seen  in  the  macula.  In  this  case  it  is 
surrounded  by  a  white  areola  (see  pages  72  and  119),  but  this  is  not 
alwa^fs  present. 

The  white  color  of  the  fundus  is  the  consequence  of  a  rapid  necrosis  of 
the  cerebral  layer,  which  receives  its  nutrition  through  the  central  artery,  in 
combination  with  an  oedema.  The  red  spot  is  brought  out  by  the  fact  that 
the  cerebral  la3'er  is  absent  at  the  fovea,  so  that  the  cedematous  tissue  is 
wanting  and  the  dark  color  of  the  fovea  stands  out  in  marked  contrast  to 
its  surroundings. 

The  arteries  gradually  refill  through  the  mediation  of  Zinn's  arterial 
plexus  (sec  page  168),  and  the  minute  branches  in  the  vicinity  of  the  macula 
become  strikingly  prominent  (Fig.  45).  but  the  retina  remains  incapable 
of  performing  its   functions  and  the  papilla  atrophies   (see  Fig.   16) • 


Fig.  45.    Occlusion  of  the  Central  Artery  in  a  Later  Stage 

The  margins  of  the  papilla  have  become  in  part  sharply  defined  again, 
its  redness  has  passed  away.  The  arteries  have  become  refilled.  The  oblit- 
erated place  can  be  plainly  seen  in  the  lower  artery  on  the  papilla.  The 
white  color  of  the  fundus  has  passed  off  to  a  considerable  extent.  The 
cherr}'  red  spot  is  no  longer  so  conspicuous,  and  there  are  signs  of  the 
coronula,  which  can  be  seen  distinctly  in  Fig.  16.  An  area  attached  like 
a  wing  to  the  papilla  has  regained  approximately  its  normal  color. 

The  vision  remained  lost  in  spite  of  the  improvement  in  the  objective 
symptoms. 


1.58 


Tab.  84. 


Fiir.  44. 


Fig.  45. 


PLATE  XXV 

Fig.  46.     Flat  Detachment  of  the  Retina 
Fig.  47.     Partial  Flat  Detachment  of  the  Retina 


Fig.  46.     Flat  Detachment  of  the  Retina 

(See  page  151) 

TIk'  papilla  is  normal  in  every  respect,  as  regards  its  color,  margins, 
level,  and  vessels. 

The  fuiulus  lias,  instead  of  its  normal  reddish  color,  a  green  gray  appear- 
ance with  bright  and  dark  bands  here  and  there.  The  vessels  have  many 
little  tortuosities,  such  as  are  scarcely  to  be  seen  in  any  other  condition. 
An  artery  makes  a  marked  bend  as  it  passes  over  the  very  white  band.  The 
entire  picture  seems  quite  dull,  because  the  vessels  have  no  light  streaks,  as 
is  almost  always  the  case  in  detachment. 

This  is  a  picture  of  an  almost  total,  but  flat  detachment  of  the  retina. 
The  detachment  does  not  extend  quite  to  the  papilla,  for  if  it  did  the  mar- 
gins of  the  latter  would  be  obscured,  and  then  the  picture  would  look  like 
one  of  optic  neuritis  (see  page  72). 

Naturally  the  vision  is  badly   impaired. 


Fig.  47.     Partial  Flat  Detachment  of  the  Retina 

The  papilla  is  normal.  The  retina  in  its  vicinity  presents  discolored 
islands  over  which  the  vessels  pass  with  a  distinct  bend.  Outward  and  upward 
from  the  papilla  is  a  large  discolored  place,  which  shows  plainly  several 
folds,  over  which  the  vessels  of  the  retina  deviate  from  their  courses.  On 
the  other  side  of  the  papilla  the  retina  is  still  attached  and  allows  the  markings 
of  the  chorioid  to  be  seen  distinctly  through  it.  Some  of  these  vessels  are 
sclerosed,  so  we  will  make  no  mistake  if  we  diagnose  this  as  an  arteriosclerotic 
detachment  of  the  rttina.  The  retinal  vessels  have  no  light  streaks,  except 
in  the  portions  that  lie  on  the  papilla. 


160 


Tab.  as. 


Fig.  46. 


Fig.  47. 


PLATE  XXVI 

Fig.  48.     Large  Gibbous  Detachment  of  the  Retina 

Fig.  49.     Detachment  of  the  Retina  Caused  by  a  Tumor  of  the 

Chorioid 


Fig.  48.     Large  Gibbous  Detachment  of  the  Retina 

(See  page   152) 

This  is  a  composite  picture,  wiiicli  depicts  wliat  the  observer  may  see  at 
varying  distances  from  the  eye  of  the  patient.  Wlicn  he  focusses  on  the 
papilla  the  detached  portion  of  the  retina  will  be  obscured,  and,  on  tiie 
other  hand,  when  he  leans  backward  in  order  to  see  distinctly  the  detached 
portion,   the   region   of  the  papilla   becomes   indistinct. 

The  margins  of  the  papilla  are  not  (juite  sharply  defined.  On  its  tem- 
poral side  is  a  distinct  conus. 

The  vessels  of  the  retina  are  in  part  accompanied  by  broad,  white  bands, 
which  have  been  jiroduced  by  transudates  that,  in  turn,  are  due  to  an  existing 
nephritis. 

The  detached  retina  protrudes  very  far  forward,  shows  depressions  and 
elevations,  and  exhibits  distinct  wavy  movements  whenever  the  patient  moves 
his  head.  These  are  to  be  ascribed  to  the  fluctuations  of  the  fluid  accumulated 
behind  the  retina. 

The  detached  portion  was  clear  on  transillumination  with  HirtzdV.s  lamp. 


Fig.  49.     Detachment  of  the  Retina  Caused  by  a  Tumor  of  the 

Chorioid 

(See  page  15'2) 

This  is  also  a  composite  picture. 

Although  it  has  a  certain  resemblance  to  the  preceding,  yet  it  presents 
certain  characteristic  differences.  The  line  of  demarcation  of  the  detached 
portion  is  (juite  sharp.  The  surface  is  smooth,  tensely  stretched,  and  in 
certain  places  the  reddish  color  of  the  tumor  can  be  seen  shining  through 
the  retina  over  it.  When  the  eye  was  transilluminated  with  HcrtzdVs  lamp 
the  region  of  the  detachment  appeared  as  a  dark  shadow. 

No  fiuctuatinff  movement  could  be  seen  when  the  head  was  moved. 


162 


Tab.  26. 


I'm.  -IS. 


1 1-.  4't. 


PLATE  XXVII 
Fig.  50.    Small  Glioma  of  the  Retina 


Fig.  50.     Small  Glioma  of  the  Retina 

(See  page  153) 

Such  a  picture  as  this  is  rarely  to  he  seen,  hecause  glioma  occurs  in  earlj 
childiiood  and  is  not  noticed  in  most  cases,  on  account  of  tlie  iihsenci'  of 
sul)jective  comphiints,  until  nearly  the  entire  space  of  the  vitreous  has  heen 
filled  hy  it  so  as  to  produce  the  so-called  amaurotic  cat's  eye.  But,  as  the 
tumor  frequently  appears  in  both  eyes,  it  occasionally  happens  to  those  who 
habitually  examine  both  eyes  with  the  ophthalmoscope  that  they  are  able  to 
see  a  glioma  of  the  size  here  depicted. 

Tiie  tumor  apparently  starts  from  the  vicinity  of  the  papilla,  which  is 
overlaid  by  it,  and  measures  Sl^X^J^L)  !'•  D.,  i.e.,  5ViX6%  mm.  It  is 
therefore  in  reality  about  as  large  as  a  pea.  This  picture  was  taken  in 
January,  1910;  in  ]March  the  tumor  was  as  large  as  a  bean,  by  October  it 
had  filled  the  entire  vitreous,  in  December,  1911,  it  broke  through  the  eye- 
ball, and  then  tlie  proliferation  advanced  very  rapidly,  so  that  at  the  time 
of  the  death  of  the  child,  in  jMay,  1912,  the  tumor  was  as  large  as  an  apple 
and  protruded  from  the  orbit. 

The  similarity  of  the  picture  to  the  preceding  ones  is  very  great,  but  it 
is  to  be  noticed  that  some  of  the  vessels  of  the  retina  lie  in  the  tissue  of  the 
tumor  itself.  At  the  upper  pole  of  the  tumor  may  be  seen  several  black 
spots  and  one  large  patch  of  atrophy,  which  indicate  a  simultaneous  disease 
of  tile  chorioid :  whether  or  not  this  h;id  anv  etiolr)gical  connection  with 
the  tumor  could  not  be  determined.  The  liemorrhages  near  the  papilla  are 
uncommon.  The  bright  zone  about  tlie  tumor  shows  that  the  pigment  epi- 
thelium of  the  retina  is  also  involved. 


164 


Tab.  27. 


Fig.  50. 


Chorioid 


Chorioid 

Preliminary  Remarks  on  the  Anatomy 

The  chorioid  is  rightly  named,  for  it  consists  essentially  of  vessels  whicli 
furnish  nutrition  to  the  macula  and  the  outer  layers  of  the  retina. 

On  account  of  the  great  abundance  of  blood  vessels  the  thickness  of  this 
membrane  varies  in  proportion  to  the  degree  to  which  they  are  filled,  and 
varies  also  in  different  places,  from  0.05  or  0.08  mm,  at  the  place  where 
it  passes  over  into  the  ora  serrata,  to  0.1  or  0.2  mm  about  the  posterior  pole. 

It  is  very  loosely  connected  with  the  sclera  (Fig.  54,  S)   through 

1,  the  lamina  suprachorioidea  (Su).  The  space  between  the  two  mem- 
branes, which  is  demonstrable  only  under  pathological  conditions,  is  known  as 
the  perichorioidal  space.  This  lamina  contains  many  pigment  cells  and  elas- 
tic fibers,  hut  no  vessels.     Then  comes 

2,  the  lamina  vasculosa,  the  layer  of  the  larger  vessels.     Next  is 

3,  the  choriocapillaris,  the  layer  of  capillaries,  which  is  of  the  greatest 
importance  in  the  pathology  of  the  diseases  of  the  chorioid  and  the  retina. 
Adjoining  this  is 

4,  the  lamina  vitrea,  also  called  the  lamina  elastica  and  the  lamina  basalis. 
Finally  comes 

5,  the  layer  of  pigment  epithelium,  which  appertains  to  the  retin;i  (see 
page  111),  but  must  be  mentioned  in  this  place  on  account  of  its  intimate 
pathological  relations  to  the  chorioid. 

The  vascular  supply  is  through  the  so-called  ciliary  vessels,  which  come 
from  the  ophthalmic  artery.  They  consist  of  from  -t  to  6  short,  and  2  long 
posterior  ciliary  arteries,  which  enter  the  eyeball  near  the  optic  nerve,  and 
4  anterior,  which  enter  near  the  limbus.  The  anterior  ciliary  arteries  run 
first  in  the  four  recti  muscles,  which  they  supply,  and  divide,  each  into  two 
branches,  before  they  reach  the  limbus. 

The  short  posterior  arteries  branch  very  quickly  after  they  have  passed 
through  the  sclera  and  the  lamina  suprachorioidea,  and  form  the  main  part 
of  the  arteries  of  the  chorioid. 

The  long  posterior  arteries  pass  without  branching  in  the  layer  of  large 
vessels  to  the  ciliary  body,  where  they  empty  into  the  circulus  arteriosus  iridis 
together  with  the  anterior  ciliary  arteries,  but  before  doing  so  they  give 
off  recurrent  branches  which  unite  with  the  capillaries  of  the  short  posterior 
arteries. 

The  short  posterior  ciliar}'  arteries  likewise  form  a  circulus  arteriosus  in 

167 


168 

the  scli'Di,  wliic'li  surrouiuls  the  papilla  ,uhI  forms  a  coiiiicction  between  tlie 
ciliary  and  the  retinal  vessels.  Tiiis  is  known  as  the  ciriniliis  artei-iosus  iiervi 
optic'i,  or  the  circle  of  Zlnn.  This  connection  is  of  but  little  practical  im- 
portance because  it  never  happens  that  a  central  artery  of  the  retina  which 
is  obstructed  in  its  central  j)()rti(>n  is  sufficiently  supplied  with  blood  throuf;-h 
this  means. 

The  chorioid  may  be  divided  into  two  very  uneciual  portions,  according 
to  the  arterial  supply,  the  posterior  and  lai-(^er  of  which  extends  from  the 
])apilla  into  the  region  of  the  eijuator,  tlu'  anterior  from  this  point  to  its 
transition  into  the  ciliary  body.  The  former  is  sup])lied  by  the  short  posterior 
ciliary  arteries,  which  therefore  form  the  jirincipal  source  of  the  nutrition 
of  the  chorioid,  while  the  second  receives  its  blood  throufrji  the  recurrent 
branches  of  the  long  posterior  ciliary  arteries. 

The  anterior  ciliary  arteries  arc  of  importance  to  the  chorioid  only  in 
so  far  as  they  unite  with  the  long  posterior,  through  the  eirculus  arteriosus 
iridis  major,  and  thert'by  with  the  short  posterior  ciliai'y  arteries,  but  this 
indirect  connection  with  the  nutrition  of  the  globe  is  of  practical  value,  for  it 
is  able  to  preserve  the  latter  when  all  of  the  posterior  arteries  have  been 
divided,  as  when  the  retrobulbar  space  has  been  exenterated  in  the  removal 
of  a  tumor. 

The  equatorial  portion  has  the  poorest  supply,  which  comes  only  through 
the  terminal  filaments  of  the  short  posterior,  and  of  the  recurrent  branches 
of  the  long  posterior  arteries.  It  is  therefore  not  an  accident  that  this  por- 
tion is  the  first,  or  the  main  one  to  be  affected  when  degenerative  processes 
take  place  in  the  eye,  as  in  chorioretinitis  pigmentosa,  and  hereditary  syphilis. 

The  venous  outflow  of  the  chorioid  is  quite  different  from  its  arterial 
supply,  as  its  veins  carry  away  not  only  tlu'  blood  from  the  chorioid  itself, 
but  also  that  from  the  ciliary  body  and  the  iris.  C'onse(iuently  they  are  far 
more  numerous  than  the  arteries  and  have  many  more  anastomoses.  They 
connnonly  pass  from  the  chorioid  into  the  sclera  behind  the  etjuator  of  the 
eye  in  the  form  of  from  i  to  6  large  vessels.  In  rare  cases  they  end  at  the 
posterior  pole  (Fig.  3),  principally  in  eyes  that  are  higlily  myopic. 

The  chorioid  contains  besides  vessels  many  collagenous  fibrils  and  elastic 
fibers,  as  well  as  a  great  (juantity  of  cliiomatophores  laden  with  pigment. 
The  latter  are  to  be  found  in  all  of  the  layers  of  the  chorioid,  with  the 
exception  of  the  choriocapillaris,  and  naturall}'  of  the  lamina  vitrea,  but 
especially  in  the  spaces  between  the  vessels. 

General  Diagnosis  of  Diseases  of  the  Chorioid,  so  far  as  They 
are  Caused  by  Diseases  of  the  Vessels 

The  schematic  drawing.  Fig.  54,  is,  with  r  material  changes,  the  same  as 
that  used  by  Krueckmann  in  Axcnfcld's  text-book. 

The  pictures  in  the  circles   show  typical  changes  that   are  to  be  ol)seryed 


16!) 

in  diseases  of  the  vessels  of  the  cliorioid.  A  glance  !it  the  succeeding  plates, 
whicli  arc  not  schematic,  for  example,  at  Fig.  74,  reveals  at  once  a  resem- 
blance to  tiie  distiirhanees  here  delineated  schematically. 

Near  each  cliange  is  presented  the  corresponding  microscopical  picture. 
The  retina  is  absent  from  all  except  Number  \'l,  for  tliis  must  be  understood 
to  be  changed  in  all,  with  tiie  exception  of  Number  I  of  course,  because,  as 
has  been  said  repeatedly,  the  outer  layers  of  the  retina  receive  their  nutrition 
from  tlie  cliorioid,  anil  disturbances  in  the  vessels  of  tiiis  membrane  nmst 
naturally  manifest  themselves  tiirough  nutritive  derangements  of  the  corre- 
sponding portions  of  the   retina. 

I.  Picture  I  shows  oplithalmoscopically  a  perfectly  normal  condition, 
which  is  likewise  normal  microscopically.  S  indicates  the  sclera ;  Su  the  lamina 
suprachorioidea ;  V  the  layer  of  large  vessels;  Ch  the  choriocapillaris ;  L  the 
lamina  vitrea;  E  tlie  pigment  epitlielium  of  the  retina,  or  at  least  its  layer 
of  basal  cells.  The  latter  is  in  tiiis  example  perfectly  uniform  and  no*:  trans- 
parent, so  that  the  cliorioid  cannot  be  seen. 

II.  In  picture  II  the  pigment  epithelium  is  destroyed  to  a  considerable 
extent  as  tlie  result  of  disease  of  tlie  subjacent  choriocapillaris;  it  is  made 
homogeneous,  if  one  may  use  such  an  expression.  In  consequence  of  the  break- 
ing down  of  this  layer  the  larger  vessels  of  the  cliorioid  can  be  seen  in  the 
form  of  a  relatively  bright  network  on  a  dark  backgrouiul,  because  of  the 
pigment  tiiat  lies  between  them.  Tlicy  appear  to  be  of  a  normal  color  and 
they  are  found  to  be  normal  under  the  microscope. 

III.  The  process  has  extended  fartiier.  The  pigment  epithelium  and  the 
choriocapillaris  iiave  coiiiplettly  disappeared.  Portions  of  the  larger  vessels 
also  are  obliterated  (A)  (a),  and  conse(]uently  appear  in  tiie  ophthalmoscopic 
picture  as  white  cords.  The  vessel  B  on  the  otiier  liand  is  in  a  normal 
condition. 

I\ .  This  presents  a  still  further  advanced  stage.  The  vessels  of  the 
cliorioid  are  almost  totally  obliterated  (C),  the  vessel  D  alone  still  contains 
a  slender  column  of  blood  within  its  thickened  walls. 

\.  The  cliorioid  has  almost  wliollv  disa])peared  ;  tiaces  only  of  the  intra- 
vascular pigment  can  be  seen.  As  there  is  no  pigment  in  the  places  formerly 
occupied  by  the  chorioidal  vessels  the  spaces  formed  by  their  absence  have 
their  forms  and  courses.  When  these  traces  of  pigment  disappear  the  pure 
white  sclera  is  laid  bare. 

VI.  This  shows  the  way  in  which  tlie  black  spots  are  brought  about. 
Here,  as  in  II,  tlie  choriocapillaris  lias  been  destroyed,  but  at  the  same  time 
bands  of  tissue  have  been  formt'd  wiiit'ii  iiave  in  their  spaces  newly  formed 
pigment  cells,  and  as  these  lie  one  behind  another  they  give  oplithalmoscopically 
the  impression  of  a  dark,  black  spot.  Further,  the  picture  shows  the  second- 
ary pigmentation  of  the  retina  that  appears  in  diseases  of  the  chorioid. 

This  is  brought  about  by  tju'  likiiding  of  the  processes  of  the  pigment 
cells  with  the  glia  tissue,  especially  with  MitclU-r'.i  supporting  cells,  so   that 


170 

the  brown  frraniilcs  of  fiisciii  pcnetnifc  into  the  retina.  It  is  solf-o\  idcnt  that 
neuli)  fornud  pigment  epithelium  can  also  proliferate  into  the  degenerated 
chorioid. 

]Vliiit  7CC  learn  from  these  schematie  pictures  in  that  not  onhi  abnormal 
pigmentations,  btit  depigmentations  as  uril,  are  to  he  looheil  upon  as 
signs  of  disease  of  tin    clmrioid. 

It  may  he  empliasi/ed  again  that  pigment  is  to  be  seen  normally  in  the 
fundus  in  two  jilaces : 

1.  The  pigment  laijer  of  tlw  retina,  wiiieh  covers  the  chorioid  and  limits 
tiie  viiw  with  the  ophthalmoscope.  It  is  only  when  tiie  nutrition  of  this 
layer  is  impaired  by  a  disease  of  the  ehoriocapillaris,  and  is  thus  caused  to 
atrophy,  that  the  markings  of  the  chorioid  can  he  seen.  Hut  it  must  he 
remembered  that  similar  ])icturcs  may  be  ijrought  about  by  a  congenital 
partial  or  total  abscnci'  of  this  pigment  layer,  as  in  albinism.  In  such  cases, 
however,  there  is  none  of  the  abnormal  heaping  of  pigment  and  disease  of  the 
vessels  that  is  to  be  seen  in  every  pathological  case.  Compare  the  periphery 
of  Fig.  57  "ith   l''ig.  8. 

2.  The  pigment  of  the  ehorioid,  whicli  lies  in  the  spaces  between  the 
vessels  of  this  membrane  and  may  last  very  long  in  spite  of  serious  chorioidal 
disease.  The  general  statement  may  be  made  that  an  abnormal  heajiing  of 
pigment  takes  place  at  the  same  time  7cherever  pigment  is  destrot/ed.  Pig- 
ment can  migrate  into  the  retina  only  when  the  lamina  vitrea  has  been 
injured,  lu  ncc  it  is  that  colloid  deposits  can  fretjuently  be  seen  on  this  lamina 
(Fig.  41)    ill   association  witii  pigmentations  of  the  retina. 

Etiology  of  Cliorioiditis. 

Almost  all  diseases  of  the  chorioid  are  sijmjitomatic  of  general  diseases, 
with  the  exception  of  those  that  are  due  to  traumatism  and  some  conditions 
that  are  congenital.  Therefore  a  very  thorough  general  craniination  is  indi- 
cated in  all  such  cases,  just  the  same  as  in  retinitis.  Although  certain  con- 
clusions can  be  drawn  in  a  number  of  cases  from  the  position,  color,  size, 
and  appearance  of  the  lesion,  yd  the  etiology  must  be  determined  mainly  by 
such  an  examination.  This  is  particularly  true  for  the  general  practitioner, 
who  can  sec  the  black  s])ots  with  the  ophthalmoscope,  but  may  not  perceive 
or  interpret  the  nu'nuter  dift'erences,  on  account  of  his  lack  of  special  practice. 
The  following  proposition  is  particularly  applicable  to  him:  //  black  or  white 
spots  are  present  in  the  fundus  a  thorough  examination  must  be  made  of  the 
organism,  zehich  is  not  to  he  confined  to  the  ordinary  physical  and  chemical 
methods  (done,  but  in  which  the  tuberculin  and  Wassermann  tests  are  to  be 
made.  A  guide  to  the  etiology  is  fre(iuently  to  be  found  in  other  ocular 
symptoms;  for  example,  if  the  cornea  is  investigated  with  the  binocular  loupe 
and  tleeply  situated  vessels,  or  fine,  central,  parencliymatous  opacities  are 
found,  which  indicate  a  past  interstitial  keratitis  and  may  persist  for  years 
after   the   subsidence   of   such    an    inflammation,    wc    have    obtained    an    almost 


171 

positive  proof  of  the  syphilitic  origin  of  the  disease.  Dots  of  pigment  in  tlie 
pupils  of  young  persons,  whicli  are  to  he  considered  as  traces  of  a  bygone 
iritis,  point  toward  the  same  etiology,  because  iritis  is  usually  of  sy])hilitic 
origin  in  yoinig  persons. 

The  following  conclusion  can  be  drawn  from  the  ophthalmoseojjic  picture 
if  we  look  for  changes  in  the  vessels. 

//  sclerosed  vessels  tire  present  in  the  chorioid  the  probable  cause  of  the 
disease  is  cither  st/phiUs,  arteriosclerosis,  or  nephritis;  if  no  such  vessels  arc 
present  the  probabje  cause  is  tuberculosis. 

In  a  small  number  of  cases  the  ilisease  in  the  chorioid  is  of  a  metastatic 
pysemic  nature,  but  these  are  usually  associated  with  a  sinmltaneous  disease 
of  the  iris  and  ciliary  body,  and,  as  tiiese  ordinarily  induce  a  great  opacity 
of  the  refractive  media,  the  lesions  in  the  chorioid  are  not  to  be  seen  with 
the  ophthahnoscope  as  a  rule.  Consequently  they  do  not  come  into  con- 
sideration in  this  place. 


DIAGNOSIS 

A.    General  Diagnosis 

After  the  diagnosis  of  a  disease  of  the  chorioid  has  been  made 
the  following  points  need  to  be  taken  into  account  in  order  to 
establish  its  etiology: 

1,  the  position  of  the  lesions  in  the  chorioid; 

2,  the  sort  of  pigmentation,  or  depigmentation ; 

3,  whether  changes  are  present  in  the  vessels  or  not; 

4,  the  form  of  the  change  in  the  chorioid; 

5,  the  differences  of  level. 

Although  we  cannot  duduce  tlic  ctiolo<ry  from  the  oplithalnioscopic  con- 
dition alone  in  all  cases,  but  very  often  have  to  rely  upon  the  general  exam- 
ination, yet  we  are  quite  frequently  able  to  do  so  by  the  observation  of  the 
following  points : 

1.   The  Position  of  the  Lesions 
in  file  Chorioid. 

It  may  perhaps  seem  rather  forced  and  schematic  to  classify  changes  in 
the  chorioid  according  to  the  position  they  occupy  in  the  fundus,  but  it  is 
not,  for  the  spot  appears  in  this  or  that  place  in  accordance  with  certain 
pathological  reasons.  For  example,  the  branchings  of  the  vessels  of  the 
chorioid  are  most  extensive  in  the  region  of  the  equator  and  the  movement 
of  the  blood  at  this  place  is  normally  rather  slow,  as  has  been  mentioned 
already,  so  if  we  imagine  a  general  contraction  of  the  capillaries  to  have 
taken  place  through  a  hj'aline  degeneration  of  their  walls,  we  will  expect 
the  first  and  most  prominent  symptoms  to  appear  just  at  this  place. 

Hence  we  differentiate  between 

(«)    the  periphery  of  the  fundus,  the  region  of  the  equator 
(6)    the  region  of  the  macula, 
(f)    the  region  of  the  papilla, 
{(1)    disseminated  distribution. 

:?.  The  Sort  of  Pigmentation 
and  Depigmentation. 

With  regard  to  the  form  of  the  pigmentation  we  differentiate 

(rt)    a  regular,  bone  corpuscle  form,  as  in  Fig.  51; 
(b)    a  lumpy  form,  which  often  appears  as  a  circle   (Fig.  53)  ; 

172 


173 

(c)    a  powder  form,  as  inougli  snuff  had  been  sprinkled  over   the   fundus 

(Fig.  63); 

((/)    jiignientation   along  the  vessels   of  the   retina    (I'ig.  57)  ; 
(<•)    an  irregular  form. 

We  meet  with  the  following  typical  forms  of  depigmentation: 

(rt)  a  diffuse  depigmentation,  chiefly  found  in  the  periphery   (Fig.  57); 

(b)  a  depigmentation  in  the  form  of  minute  spots,  as  in  Fig.  55; 

(f)  depigmentation    in    medium-sized   spots,   as   in   Fig.    79; 

(f/)  irregular. 

S.  Are  Changes  Present  in  the  Vessels  or  Not? 

Vascular  changes,  especially  of  the  large  vessels,  ordinarily  give  a  beauti- 
ful, characteristic  picture  (Fig.  64). 

In  many  cases  changes  in  the  vessels  cannot  be  seen,  but  their  presence 
may  be  inferred.  For  example:  Diseases  of  the  choriocapillaris  lead  to 
dccolorizations  of  the  pigment  epithelium;  consequently  we  are  justified  in 
the  conclusion  that  there  is  a  disease  of  the  choriocapillaris  whenever  we  see 
such  depigmentations  with  the  ophthalmoscope  (see  Fig.  57)-  Another 
example:  When  the  vessels  of  the  chorioid  sclerose  and  gradually  become 
destroyed,  we  can  often  recognize  the  positions  they  formerly  occupied  from 
the  fact  that  the  pigment  lying  between  them  outlines  their  margins,  as  in 
Circle  V  of  Fig.  54.  When  this  pigment  disappears  also  it  leaves  a  pure 
white  surface,  that  of  the  sclera.  In  spite  of  the  fact  that  the  vessels  can 
no  longer  be  seen  we  are  justified  in  ascribing  these  white  spots  to  vascular 
changes  if  we  can  find  sclerosed  vessels  in  other  parts  of  the  fundus. 

4.  Tl)e  Form  of  the  Change. 

The  forms  of  some  changes  are  so  characteristic  that  we  can  deduce 
from  them  at  once  some  conclusions  as  to  their  etiology.     Among  these  are: 

(a)  Ruptures  of  the  chorioid  after  contusions. 

These  are  white,  usually  crescentic,  and  lie  concentrically  to  the  margin 
of  the  papilla.  Their  margins  are  sharply  cut  and  frequently  covered  with 
pigment.  In  most  cases  they  lie  to  the  outer  side  of  the  papilla,  more  rarely 
to  its  nasal  side.      The  retinal   vessels  pass  smoothly  over  them. 

In  rare  cases  the  ruptures  are  situated  more  peripherally,  at  the  place 
where  the  blow  was  received,  and  ai-e  not  concentric  to  the  papilla.  In  such 
cases  the  lesion  is  to  be  considered  as  due  not  to  contrecoup,  but  to  the  direct 
eff'ect  of  the   injury. 

(/;)  Large,  elevated,  brilliant  white  patches,  strewn  richly  with  pigment, 
at  the  posterior  pole  of  the  eye,  chorioretinitis  prolifcrans,  are  indicative  of 
transverse  gunshot  wounds  of  the  orbit. 

5.  Differences  of  Lerel. 

Finally  the  aid  of  parallactic  displacement  must  be  sought  in  the  exam- 
ination, because  depressions   and  elevations   from  the  ordinary  level   are  met 


Mi 

with.      First  wu  iiavc  to  tliinlv  of  proiifi.riitions  of  connective  tissue,  some  of 
which  ill''-  caused  by  injuries,  some  by  general  diseases. 

Diff'.^ivnces  of  level  can  also  he  detectt'd  in  colohoina  of  tiie  chorioid,  of 
the  macula,  and  of  the  optic  nerve,  in  the  so-called  "stapiiyloiua  verum,"  and 
in  tumors  of  the  chorioid. 

B.    Special  Diagnosis 

Note:  As  the  retina  is  always  secondarily  involved  in  diseases  of  the 
chorioid  the  term  ciiorioretinitis  is  preferable  to  chorioiditis. 

(a)  Changes  in  the  Chorioid  and  Retina  Which  Occur  Chiefly 
or  Exclusively  in  the  Periphery 

We  will  begin  witii  these  because  they  are  the  most  common,  and  will 
consider  first   the  diseases   tliat    are   characterized   by 

Collections  of  Pigment 

1.  Collections  of  pigment  that  resemble  bone  corpuscles  are  found  in 
choriorciinitis  pigmentosa,  or,  a  better  name  for  the  disease,  pigment  atrophy 
of  the  retina.  Fig.  51  shows  these  collections  in  their  characteristic  form. 
They  are  of  a  deep  black  color,  may  be  more  or  less  abundant,  and  may  be 
rather  lum[)y,  as  depicted  on  the  plate,  or  may  be  more  delicate  in  their 
tracery.  The  form,  which  is  suggestive  of  the  microscopic  appearance  of 
bone  corpuscles,  is  brought  about  by  the  fact  that  the  pigment  follows  along 
the  branching  course  of  the  smaller  arteries  and  the  capillaries  of  the  retina. 
\ot  infrequently  even  the  large  arteries  may  be  seen  to  have  mantles  of 
pigment.  At  first  the  pigment  is  only  sparsely  present,  but  it  gradually' 
becomes  more  abundant  as  the  disease  progresses  toward  the  macula.  The 
vessels  of  the  retina  are  greatly  contracted.  The  markings  of  the  chorioid 
become  visible  in  consequence  of  the  atrophy  of  the  pigment  layer,  and  oblit- 
erated vessels  can  often  be  seen  distinctly.  The  entire  fundus  acquires  a 
peculiar,  leaden  color,  from  which  the  disease  can  frequently  be  recognized 
at  the  first  glance.  The  papilla  is  atrophic  in  advanced  cases,  and  usually 
has  a  yellowish  hue  (see  page  52). 

The  central  vision  may  remain  good  for  a  long  time,  but  the  functional 
disturbance  in  the  periphery  is  shown  by  a  contraction  of  the  visual  field 
and  the  onset  of  a  marked  hemeralopia. 

A  form  of  chorioretinitis  is  also  to  be  met  with  which  exhibits  the  same 
subjective  sj'mptoms  as  pigment  atrophy,  but  is  destitute  of  ])igment.  This 
is  known  as  retinitis  pigmentosa  sine  ])igmento.  Retinitis  punctata  albescens, 
which  causes  similar  subjective  symptoms,  but  is  characterized  by  the  pres- 
ence of  little  white  spots,  has  a  similar  etiology. 

The  disease  is   congenital   and  usually  occurs   in    children   whose  parents 


175 

are  nearly  related.  This  fact  differentiates  it  from  chorioretinitis  pigmentosa 
secundaria,  which  exhibits  collections  of  pigment  of  a  similar  shape  as  the 
consequence  of  a  plainly  demonstrable  sclerosis  of  the  vessels  of  the  chorioid, 
often  confined  to  circumscribed  portions  of  the  periphery  (see  Fig.  52 )i  but 
the  secondary  pigmentations  are  usually  of  a  less  regular  form  (compare 
with  Fig.  67). 

2.  A  second  form  of  pigmentation  of  tlie  periphery  of  the  fundus  is  by 
masses  of  pigment,  xchich  are  often  unnidar, 

as  shown  in  Fig.  53.  This  pigmentation  is  by  no  means  as  regular  and  is 
not  as  delicate  as  that  seen  in  chorioretinitis  pigmentosa;  it  is  usually  found 
only  at  certain  places  in  the  periphery.  The  retina  and  the  optic  nerve 
are  not  as  seriously  involved.  This  is  one  type,  the  grosser,  of  hereditary 
syphilis  of  the  eye,  tlie  other  is  characterized  by  the  so-called 

3.  Snuff  fundus, 

shown  in  Fig.  63.  The  pigment  is  present  here  in  tlie  form  of  very  minute 
points,  between  which  are  little,  roundisii  depigmentations.  These  produce 
an  appearance  that  has  given  rise  to  the  name  "pepper  and  salt  fundus." 
Although  this  is  fairly  rare  in  a  distinct  form,  cases  in  wliich  it  is  suggested 
are  rather  common.  Tlie  changes  are  to  be  seen  most  frequently  in  the 
lower  periphery  of  the  eye. 

4.  Isolated  spots  of  pigment, 

such  as  are  seen  in  Fig.  80,  are  likewise  found  in  the  pe^ipher}^  Thev  are 
usually  surrounded  by  a  bright  halo.  They  are  caused  by  either  hereditary 
or  acquired  syphilis.  When  they  are  due  to  hereditary  syphilis  the  former 
existence  of  an  interstitial  keratitis  can  frequently  be  proved  either  by  the 
history,  or  by  finding  blood  vessels  situated  deeply  in  the  tissue  of  the  cornea. 

Depigmenfation  in  the  Periphery. 

No  attention  will  be  jiaid  iicre  to  such  depigmentations  as  occur  acci- 
dentally in  the  periphery,  like  those  shown  in  Fig.  75,  but  only  to  those 
that  are  typical. 

1.  Discrete  Depigmentations. 

These  are  met  with  in  the  pepper  and  salt  fundus,  in  which  the  little 
round,  bright  spots  may  be  more  muiieroiis  than  tiie  dots  of  jiigment.  Such 
a  fundus  is  shown  in  Fig.  55.  In  many  cases  the  spots  may  be  mistaken  for 
colloid  deposits  on  the  vitreous  lamella,  which  are  described  on  page  127, 
and  depicted  in  Fig.  41,  but  they  are  rather  larger,  and  are  to  be  found 
chiefly  in  the  periphery.  It  is  only  in  severe  cases  that  they  extend  as  far 
as  the  papilla.  They  are  to  be  seen  in  childhood,  wliilu  colloid  deposits  first 
appear  in  old  age,  as  a  rule.  They  are  due  to  hereditary  syphilis  and  are 
often  met  with  in  company  with  other  signs  of  that  disease,  such  as  diseases 


176 

of  the  vt'ssi'ls  .-uul  piyiiR'iitat  i()n>.  A  wvy  had  casu  of  tliis  nature  is  shown 
in  Fi<j.  56,  ill  wliicli  tlu'  ntina  is  involved  tlirough  destniction  of  its  vessels, 
and  the  ()|>tic  nerve  is  atropiiie. 

2.  Superficial  Dcpigmcntdt'toiis, 

as  tlie  result  of  thi'  destruction  of  thi'  chorioeapillaris,  ari'  likewise  often  due 
to  hereditary  syphilis.  The  peripheral  part  of  the  fundus  is  hrightencd  and 
the  large  vessels  of  the  chorioid  can  be  seen,  although  they  are  invisible  in 
the  central  j)ortion.  This  can  lie  distinguished  from  a  partial  albinism,  such 
as  is  shown  in  Fig.  8,  by  the  smallness  of  the  arteries  of  the  retina  and  the 
presence  of  detached  spots  of  pigment. 

These  depigmentations,  which  are  usually  found  only  of  the  extent  and 
intensity  depicted  in  Fig.  57,  may  spread  more  or  less  over  the  fundus  in 
exceptional  cases,  but  even  tlun  they  are  most  marked  in  the  periphery. 
Fig.  58  is  a  picture  of  such  a  case,  in  which  the  retina  and  optic  nerve 
were  involved  as  well  as  the  chorioid. 


(b)  Changes  in  the  Chorioid  in  the  Region  of  the  Macula 

The  tliffuse  changes  in  the  chorioid,  which  will  be  desci-ibed  lati'r,  may 
involve  the  region  of  the  macula  under  certain  conditions,  as  shown  in  Fig.  80, 
but  it  is  proposed  to  deal  in  this  place  only  with  the  typical  diseases  of  the 
macula  that  are  characterized  by  certain  peculiarities.  It  may  be  stated 
here  that  in  the  beginning  of  a  disease  of  the  macula  the  region  of  the  latter 
appears  to  be  slightly  hazy,  and  that  the  reflex  ring  about  it  is  abolished. 

1.   Arteriosclerotic  Changes  in   the  Macula. 

This  is  often  called  senile  degeneration,  yet  it  is  by  no  means  confined 
to  old  age,  for  premature  arteriosclerosis  may  occur  in  young  persons  occa- 
sionall}^  the  same  as  senile  cataract.  The  varying  types  and  intensity  of 
such  changes  are  depicted  in  Figs.  59  to  62.  The  markings  of  the  chorioid 
stand  out  with  vuiusual  distinctness,  perhaps  with  abnormal  touches  of  pig- 
ment, or  little  bright,  yellowish,  or  reddish  yellow  points  may  be  seen  with 
a  more  or  less  abundant  proliferation  of  pigment  between  them.  Colloid 
deposits  are  sometimes  found  in  their  vicinity.  The  changes  are  very  trivial 
ivnd  cause  no  symptoms  at  all,  unless  they  happen  to  be  situated  in  the 
center  of  the  macula.  Aside  from  these  relatively  insignificant  changes  in 
the  macula,  which  arc  not  infrequently  associated  with  a  development  of 
connective  tissue,  scleroses  are  to  be  found  in  the  large  vessels,  as  shown 
in  Fig.  64.  Such  an  arteriosclerosis  can  be  simulated,  in  rare  cases,  by 
a  nephritic  disease  of  the  vessels  of  the  chorioid,  but  it  rarely  happens,  in 
such  cases,  that  such  lesions  of  the  retina  as  oedema  and  hemorrhages  are 
lacking  (see  the  nasal  side  of  the  papilla  in  Fig.  69)- 


177 

2  ..Changes  in  the  Macula  Cauxid  by  Contusions,  or  b/j  the  Presence  of  a 
Foreign  Body  in  the  Eye 

resemble  closely  those  that  have  just  been  described.  For  tliis  reason,  and 
because  it  is  quite  seldom  that  they  are  to  l)e  seen,  it  does  not  seem  best  to 
devote  a  picture  to  tiiem. 

3.  The  Changes  in  the  Macula  Caused  by  High  Myopia  have  been  thus 
described  by  r.  Michel: 

"Sometimes  little  brigiit  spaces  are  found  in  the  layer  of  pigment  epithe- 
lium, and  at  the  same  time  small  heaps  of  pigment,  or  short  bright  stripes, 
arranged  in  rows  or  formed  into  a  network.  In  many  cases  whiti.sh  band.s 
or  lines,  not  edged  with  pigment,  extend  out  from  tlie  margins  of  the  staphy- 
loma, which  are  joined  in  the  region  of  the  macula  l)y  transverse  lines  (Fig. 
71),  or  yellowish  points  may  be  visible  near  one  another.  In  other  cases  a 
hemorrhage,  or  a  dirty  gray,  or  greenish  little  elevation,  or  a  deep  black  spot 
of  pigment,  takes  the  place  of  the  macula,  when  hemorrhages  may  be  present 
in  the  vicinity,  and  it  sometimes  happens  that  a  thrombosed  vein  of  the 
chorioid  is  to  be  seen,  running  near  the  entrance  of  the  optic  nerve  and 
toward  tiie  macula.  Aside  from  the  possibility  of  an  innnediate  extension 
of  the  staphyloma  to  the  region  of  tiie  macula  in  cases  of  high  myopia,  tlie 
place  of  the  macula  may  be  occupied  by  a  single  white,  sharply  defined  large 
spot  (Fig.  72),  or  several  smaller  ones  of  the  same  nature,  bordered  by  a 
more  or  less  broad,  often  irregular,  fringclike  edge  of  pigment,  frequently  in 
the  form  of  a  ring."' 

The  changes  that  take  place  on  the  papilla,  as  well  as  the  shadows  ef 
the  so-called  stapjiyloma  verum  (Fig.  73),  have  been  mentioned  on  page  37. 

These  changes  in  myopia  are  to  be  ascribed  to  the  eft'tct  of  the  stretching 
exerted  upon  the  vessels  of  the  chorioid,  and  upon  the  tissue  of  both  this 
memlu'ane  and  tlie  retina,  in  the  temporal  portion  of  tlie  posterior  segmenb 
of  the  globe,  which  sometimes  causes  ruptures  and  apertures  in  the  elastic 
lamina,  as  well  as  disease  of  the  chorioidal  vessels. 

4.  Tlie  So-called  Coloboma   of  the  Macula. 

This  is  a  roundish,  or  transversely  oval  spot  in  the  region  of  the  macula, 
which  measures  3  P.  D.  horizontally  by  from  1  to  3  P.  D.  verticallv,  has  an 
edge  of  pigment,  and  usually  present  a  network  of  tlie  same.  Its  comparatively 
large  size  and  its  regular  margins  differentiate  this  from  other  spots  in  the 
chorioid,  with  which  it  is  frequently  associated. 

(c)    The  Changes  in  the  Chorioid  about  the  Optic  Nerve, 

such  as  the  conus,  the  staphyloma,  the  halo,  and  jieripapillary  atrophy  of 
the  vessels,  have  been  dealt  with  for  the  most  part  on  page  33. 


178 


Peripapillary  Sclerosis  of  the  Vessels 

may  be  nientiontd  afraiii.  Arteriosclerosis  affects  two  regions,  tliat  of  the 
macula,  and  that  of  the  entrance  of  tlie  optic  nerve. 

In  Fig.  65  may  he  seen  plainly  sclerosed  large  vessels,  some  of  them 
still  containing  .slender  columns  of  blood,  which  resemble  those  shown  in 
the  schematic  drawing  in  Fig.  54.  Tiiis  form  of  atrophy  of  the  chorioid  is 
commonly  progressive,  and  may  spread  from  this  place  over  the  entire  fundus 
(Fig.  67).  More  or  less  abundant,  irregular  heaps  of  pigment  appear  at 
the  same  time.  The  vessels  of  the  retina  may,  or  may  not  be  involved  in 
the  sclerosis.  The  prognosis  of  sclerosis  of  the  vessels  of  tlie  chorioid  is  by  no 
means  as  bad  as  that  of  sclero.sis  of  those  of  the  retina  (see  page  1.'53). 

Such  an  extensive  vascular  sclerosis  may  be  cau.sed  by  hereditary  syphilis 
in  exceptional  cases.  Fig.  68  portrays  a  case  of  this  nature  in  which  the 
vessels  of  tiie  chorioid  were  sclerotic  over  almost  tlie  entire  fundus.  It  is 
only  in  the  region  of  the  macula  tiiat  a  place  can  be  seen  which,  although 
changes  are  present,  is  still  capable  of  performing  its  functions. 

Ruptures  of  the  Chorioid 

are  characteristically  situate'!  about  tlie  entrance  of  tlie  optic  nerve  (see 
page  12(5  and  Fig.  83).     Tliis  is  true  also  of  the  typical 

Coloboma  of  the  Chorioid  (Figs.  84  and  85). 

Colobomata  of  tlie  chorioid  lie  behiw  tlie  })a]jilla,  in  the  inverted  image 
above,  and  have  the  form  of  an  egg,  or  of  a  shield.  The  greater  diameter 
is  always  vertical.  The  color  is  a  brilliant  white,  with  which  a  gray  blue 
tone  is  often  mixed,  and  sometimes  some  brownish  ])laces  can  be  seen.  A 
special  tinting  is  given  by  irregular  excavations  which  form  little  hills  and 
valleys.  In  many  cases  the  coloboma  is  bordered  by  a  sharply  defined,  black 
edge  of  pigment,  and  flecks  of  pigment  can  often  be  seen  in  the  coloboni.i 
itself.  In  addition  to  the  vessels  of  the  retina,  which  run  smoothly  over  the 
white  surface,  branches  of  the  ciliary  vessels  that  pierce  the  sclera  can  usually 
be  seen ;  these  are  often  twisted  like  corkscrews.  The  size  of  the  coloboma 
varies;  in  many  cases  it  is  situated  quite  peripherally  and  can  be  seen  only 
when  the  patient  looks  far  downward,  in  oth(  rs  it  begins  just  below  the  papilla 
(Fig.  84),  and  it  may  extend  above  the  disk  and  involve  the  macula   (Fig. 

85). 

The  extent  of  a  coloboma  does  not  necessarily  accord  with  a  correspond- 
ing defect  in  the  field  of  vision ;  on  the  contrary,  the  latter  may  sometimes  be 
perfectly  normal;  this  depends  on  the  extent  to  which  the  retina  is  involved. 

A  coloboma  is  to  be  considered  as  a  true  arrest  of  development,  due  to  a 
faulty   closure  of  the  fetal  ocular  cleft.      Frequently  it   is  met   with   in  com- 


179 

pany  witli  othor  inalforinations  of  the  eye,  such  as  colohonia  of  tlic  iris, 
micropiitiiahiios,  straliisimis,  ami  nystafrimis,  as  well  as  of  other  parts  of 
the  body. 

An  ophtiialiiioseo|)ie  picture  wiiich  is  seldom  seen  is  known  as  coloboma 
of  the  optic  nerve.  The  papilla  is  doubled  in  size  and  appears  as  a 
roundish,  or  vertically  oval  hollow. 

(d)   The  Disseminated  Form  of  Chorioretinitis  is  characterized 

by  the  fact  that  it  appi'ars  in  multiple  spots,  little  if  any  larger  than  the 
papilla,  wiiich  are  usually  situated  at  the  posterior  pole  of  the  eyeball.  These 
spots  may  be  fresh  or  old. 

Fresh  spots  are  small,  roundish,  rarely  elongated,  gray,  and  about  a  quar- 
ter of  the  size  of  the  papilla  when  they  are  not  confluent.  The  spots  them- 
selves cannot  be  seen,  the  accompanying  a?dcma  of  the  retina  alone  is  visible. 
They  can  be  perceived  most  readily  when  a  vessel  of  the  retina  happens  to 
pass  over  them  (see  the  vein  running  downward  and  inward  in  Fig.  78);  the 
vessel  is  raised  at  such  a  place,  is  wavy,  and  in  many  ca.ses  is  covered  partly 
or  wholly  by  the  oedema. 

These  spots  are  usually  caused  bv  tuberculosis  or  syphilis.  The  latter  dis- 
ease is  particularly  to  be  suspected  when  they  lie  in  the  anterior  segment  of 
the  chorioid,  and  when  the  diagnostic  signs  mentioned  on  j^age  170,  deep  ves- 
sels and  central  opacities  of  the  cornea,  dots  of  pigment  on  the  lens,  and 
sclerotic  vessels  of  the  chorioid,  are  present.  But  syphilitic  diseases  of  the 
chorioid  very  often  manifest  themselves  from  the  start  through  a  sclerosis 
of  its  vessels  (compare  with  the  schematic  drawings  in  Fig.  54)- 

With  regard  to  the  differential  diagnosis  from  spots  having  a  similar  ap- 
pearance, see  page  126. 

Old  atrophic  spots  are  found  in  a  great  variety  of  forms.  The  develop- 
ment of  a  fresh  spot  into  an  atrophic  one  can  be  watched  in  comparatively 
few  cases.  We  usually  see  the  picture  produced  by  the  bygone  process  and 
have  to  try  to  draw  conclusions  from  it.  It  is  clear  at  once  in  most  cases 
that  the  spot  is  chorioiditic  and  not  retinitic,  for  a  pigmentation  characteris- 
tic of  a  chorioiditic  spot  is  almost  never  lacking  cither  in  the  spot  itself,  or 
in  its  immediate  vicinity.  Syphilitic  spots  are  usually  nnich  more  abundantly 
pigmented  than  the  tuberculosis,  so  that  a  weak  pigmentation  is  indicative  of 
tuberculosis.  The  color  may  be  j^ellowish,  yellowish  graj',  or  pure  white; 
this  depends  on  whether  portions  of  the  choi'ioid  are  present,  or  the  mem- 
brane has  been  completely  destroyed.  The  white  color  is  brought  about 
either  by  the  sclera  shining  through  the  atro[)hic  chorioid.  or  by  the  forma- 
tion of  a  hyaline,  cicatricial,  connective  tissue  in  the  place  of  the  membrane 
that  has  been  desti-oyed. 

Atrophic  spots  are  divided  i:ito  two  varieties: 

1,  Those  that  are  •without  visible  changes  in  the  vessels; 

2,  Those  that  are  Kith  visible  changes  in  the  vessels. 

Tuberculosis  is  the  principal  cause  in  cases  that  belong  to  the  first  group, 


180 

while  svpliilii^,  iirtcTio.sck'rosi.s,  and   iRphritis   must   be   taken  into  account   in 
those  that  belong  to  the  second. 

1.  Atrophic  Spots   Wittioiit 
Visilile  ('liaiificft  in  the   Vt'sacls. 

One  of  the  most  important  services  rendered  to  the  world  by  v.  Michel 
was  to  call  attention  to  tul)erculosis  as  one  of  the  main  causes  of  chorio- 
retinitis. Altliollfi'ii  this  idea  met  at  first  with  the  stron^rest  opposition,  he 
had  tlie  satisfaction  of  seeing  it  adopted  by  almost  all  ophthalmologists.  It 
was  he  also  who  pointed  out  the  diagnostic  importance  of  the  changes  in  the 
vessels.  Although  we  nnist  generally  leave  the  final  determination  of  the 
etiologv  <d'  a  disseminated  ciiorioidit  is  to  tiie  general  examination,  yet  the 
differential   points  mentioneil  do  good  service. 

The  number  of  the  spots  is  extremely  variable;  sometimes  only  a  single 
one  is  accidentally  discovered  in  an  ophthalmoscopic  examination,  sonutimes 
great  numbers  are  scattered  over  the  entii-e  fundus.  Fresh  spots  may  be 
present  along  with  old  ones.  The  spots  are  usually  roundish,  frequently  con- 
tinent, and  have  festooned  margins.  In  their  vicinity  is  often  to  be  found  a 
depigmentation  of  the  pigment  epithelium,  which  looks  like  the  decoloration 
produced  by  a  chemical  substance.  The  pigmentation  connnonly  is  slight. 
Such  a  sharp  pigment  edge  as  is  observed  in  syphilis  (Fig.  74)  is  almost 
never  seen.  The  jngmcnt  usually  lies  in  other  places,  near  by,  yet  not  innne- 
diatelv  connected  with  the  sjiots.  At  most  the  spot  has  in  its  center  a  little 
dot  of  pigment,  as  though  the  nodule  in  its  growth  had  lifted  up  a  little  piece 
of  the  pigment  epithelium. 

The  combination  of  such  details  may  give  rise  to  the  greatest  variety  of 
pictures,  as  may  be  seen  in  Figs.  78  find  79. 

The  vessels  of  the  retina  are  intact  ami,  in  many  cases,  are  rather  fuller 
than  usual. 

2.  Alropliic  Spots   iritli 
Changes  in  tlic  Vessels. 

The  essential  points  regarding  the  appearance  and  origin  of  such  diseases 
of  the  chorioid  as  are  produced  by  changes  in  the  vessels  have  been  described 
with  the  aid  of  schematic  drawings.  When  we  look  at  Fig.  74  we  find  that 
the  schematic  di-awing  resembles  actuality  very  closely.  The  number,  size, 
and  form  of  these  spots  vary  a  great  deal.  Usually,  when  the  lesion  does  not 
spread  diffusely,  they  are  bordered  by  a  distinct,  black  ring,  and  more  or 
less  abundant  masses  of  pigment,  which  vary  in  size  and  number,  are  also 
present.  In  rare  cases  the  spot  is  covered  l)y  a  network  of  pigment  that 
resembles  in  its  form  chorioretinitis  pigmentosa  (Fig.  52). 

Under  certain  circumstances  a  quite  diffuse  arrangement  of  changes  in 
the  vessels  of  the  chorioid.  heaps  of  pigment,  and  totally  atrojjhic  places  h 
brought  about  by  the  confiuence  of  separate  spots,  as  is  shown  in  Figs. 
76  and  77. 


181 

Syphilis,  arteriosclerosis  and  nephritis  are  tlie  cliief  causes  in  these  cases, 
less  often  they  are  due  to  diabetes,  or  malaria.  Hence  a  general  examination 
is  always  necessary. 

The  degree  to  wliich  the  vision  is  disturbed  depends  mainly  on  the  involve- 
ment of  the  macula;  at  first  objects  seem  to  be  distorted,  i.e.,  the  patients 
have  metamorphopsia,  later  central  relative  and  aljsolute  scotomata  appear. 
Sometimes  we  arc  surprised  to  find  that  the  vision  is  comparatively  good  in 
spite  of  the  extensive  changes  in  the  fundus. 

Changes  in   the.  Chorioid 
with  Differences  of  Level. 

The  ordinary  changes  in  the  chorioid  generally  cause  no  differences  of 
level,  as  a  defect  that  may  be  produced  is  balanced  by  a  compensating  pro- 
liferation of  tissue,  and  the  reverse.  Yet  in  a  number  of  tliese  diseases  a 
difference  of  level  can  be  detected  by  means  of  parallactic  displacement  and 
the  observation  of  bends  in  the  course  of  a  vessel,  showing  eitlier  a  hollow 
or  an  elevation. 

1.  A  hollow  is  found  cliiefly  in  colobomata  of  the  cliorioid  (see  Fig.  85), 
and  in  many  cases  of  jiigh  myopia.  In  the  latter  it  is  known  as  a  stapiiyloma 
verum   (Fig.  73). 

2.  An  elevation  is  observed  in  tumors,  either  inflammatory  or  noninriani- 
matory,  and   in  detaclmicnt  of  tlie  cliorioid. 

The  noninjiamiiKitorii  tumors,  such  as  sarcoma  and  metastatic  carcinoma 
of  the  chorioid,  make  themselves  manifest  through  the  accompanying  detach- 
ment of  tlie  retina  and  liave  been  described  in  connection  witii  this  condition, 
see  page  152. 

Inflcnmnatory  tumors  are  of  cither  a  syphilitic,  or  a  tuberculous  nature. 
The  former,  gummata,  are  accustomed  to  start  with  very  severe  signs  of 
inflammation,  which  extend  far  into  tlie  neighboring  tissues,  and  often  render 
an  exact  diagnosis  impossible  by  an  opacity  in  the  vitreous.  After  they 
have  cleared  up  under  suitable  treatment  only  a  harmless  atrophic  spot  is 
usuall}'  to  be  seen  at  the  affected  place. 

Tuberculous  inflavimation,  conglomerate  tubercle,  may  greatly  resemble 
a  gumma  at  first,  but  its  result  is  commonly  not  so  benign.  It  often  per- 
forates the  sclera  and  proliferates  into  the  tissues  of  the  orbit,  rendering 
exenteration  of  that  cavity  necessary.  The  conglol)ate  tubercle  near  the 
head  of  the  optic  nerve  may  threaten  life  through  the  production  of  a  menin- 
gitis by  proliferation  along  the  sheath  of  the  optic  nerve. 

In  benign  cases  the  nodules  are  transformed  into  connective  tissue,  which 
gives  the  impression  of  a  mountain  covered  witli  snow  by  Its  bright  color 
and  its  elevations  and  depressions.  Very  little  pigment  is  found  in  its  neigh- 
borhood. 

Detachment  of  the  chorioid.  both  circumscribed  and  total,  occurs,  but  it 
is  rarely  diagnosed  during  life,  it  is  observed  more  often  in  pathological 
preparations. 


182 

It  appears  as  a  dark  surface  with  parallactic  displacement  of  the  vessels 
of  the  retina,  but  perceptible  marking's  of  tiie  cliorioid  (compare  with  detacii- 
mcnt  of  the  retina,  page  152).  \Vheii  it  is  particularly  large  it  appears  as 
a  light  brown   protrusion. 

It  is  observed  most  often  witli  iuiiiorrhages  into  the  perichorioidal  space, 
such  as  occur  in  high  nij'opia  and  .ifter  wounds,  in  congenital  buphthalmos, 
and  after  extraction  of  cataract.  Total  detachment  takes  place  in  phthisis 
bulbi. 

Elevations  due  to  the  jjroViferatioJi  of  connective  tissue  in  the  chorioid, 
chorioretinitis  proliferans,  such  as  are  observed  in  arteriosclerosis,  tubercu- 
losis, and  especially  after  wounds,  are  relatively  frequent.  Chorioretinitis 
proliferans  forms  a  typical  picture  after  transverse  shot  wounds  of  the  orbit, 
with  the  production  of  white,  elevated  spots  associated  with  an  extremely 
rich  development  of  pigment.  The  way  in  which  this  is  brought  about  is  that 
the  eyeball  is  pressed  in  from  behind  by  the  explosive  force  of  the  shot  pass- 
ing rapidly  through  the  orbit,  and  the  chorioid  is  thereby  ruptured  in  man}" 
places.  The  excessive  cicatrization  set  up  in  healing,  together  with  the 
organization  of  the  hemorrhage,  gives  the  characteristic  picture. 


PLATE  XXVIII 

Fig.  51.     Retinitis  Pigmentosa,  or  Pigment  Degeneration  of  the 

Retina 

Fig.  52.    Secondary  Retinitis  Pigmentosa 


Fig.  51.     Retinitis  Pigmentosa,  or  Pigment  Degeneration  of  the 

Retina 

(Sec  l)agv   17-i) 

Tlic  tvro  is  apt  to  call  cxciv  (liscasu  of  the  fundus  associated  with  colii'C 
tions  of  pitriiient  retinitis  pigmentosa,  but  tliis  name  siioiild  be  applied  only 
to  a  certain  distinctive  clinical  picture,  with  the  exception  of  secondary 
retinitis  pigmentosa,  described  be  low.  Tin  form  uiid  position  of  the  spots 
of  pigment  are  characteristic.  They  lie  in  the  outermost  periphery  and 
advance  frradually  toward  tiie  papilla.  They  resemble  in  form  the  micro- 
scopic picture  of  bone  corpuscles,  because  the  pigmentation  follows  the  capil- 
laries of  the  retina.  It  also  follows  the  larger  vessels,  which  sometimes  have 
mantles  of  pigment  (see  also  Fig.  57)-  Other  characteristics  are  the  color 
of  the  papilla  and  the  color  of  the  fundus.  The  papilla  is  of  a  waxy  yellow- 
in  marked  cases,  and  the  fundus  has  a  blue  gray  tone,  which  may  suggest  the 
correct  diagnosis  at  once.  The  vessels  of  the  retina  are  quite  drawn  out 
and  of  very  small  caliber.  In  most  cases  an  involvement  of  the  chorioid  is 
shown  by  the  presence  of  sclerosed  vessels  and  depigmented  places.  Such  a 
condition   may  be  seen   in   this   picture   in    thi'  vicinity  of  the  papilla. 

Among  the  subjective  symptoms  are  an  extreme  concentric  contraction 
of  the  field  of  vision,  and  a  functional  disturbance,  the  so-called  hemeralopia. 
The  predisposition  to  the  disease  is  congenital;  it  often  affects  children  of 
consanguineous  ])a rents. 


Fig.  52.     Secondary  Retinitis  Pigmentosa 

Tiiat  form  of  retinitis  pigmentosa  in  which  the  disease  of  the  vessels  of 
the  chorioid  is  particulai-ly  marked  is  designated  by  this  term.  Changes  in 
these  vessels  are  met  with  in  the  typical  form  of  the  disease,  as  was  mentioned 
above,  so  this  one  differs  from  it  only  in  degree. 

But  it  is  customary  also  to  call  a  condition  "secondary  retinitis  pigmen- 
tosa" which  in  no  way  corresponds  in  etiology,  extent,  or  state  of  the  papilla, 
to  the  typical  form,  although  the  shape  of  the  deposits  of  pigment  is  the 
same.  Such  a  condition  is  shown  in  this  picture,  which  was  taken  from  the 
eye  of  a  woman  .50  years  old,  who  had  arteriosclerosis.  The  changed  vessels 
of  the  chorioid,  which  have  produced  an  atrophy  that  resembles  a  staphyloma, 
can  be  seen  distinctly  in  the  vicinity  of  the  papilla ;  similarly  sclerosed  vessels 
may  also  be  seen  in  an  area  that  lies  far  in  the  periphery.  This  area  is 
covered  by  a  network  of  "bone  corpuscles."  A  similar  network  can  also  be 
seen  at  a  place  where  the  sclerosed  vessels  are  not  so  plainly  visible. 


ISi 


Tab.  88. 


Fig.  52. 


PLATE  XXIX 
Fig.  53.    Grossly  Pigmented  Fundus  of  Hereditary  Syphilis 


Fig.  53.    Grossly  Pigmented  Fundus  of  Hereditary  Syphilis 

(See  page  I  To) 

In  contrast  with  the  preceding  pictures  tlie  pigment  is  seen  in  this  one 
to  be  in  large,  round  masses,  whicii  have  a  distinctly  circular  form  in  the 
places  where  it  is  less  dense;  in  other  places  the  pigment  has  blended  into  an 
inextricable  network  of  blaclc  ])oints.  The  detached  groups  of  spots  are 
separated  by  a  zone  of  depigme!ited  tissue  from  tlie  normal.  A  depigmented 
zone  is  also  to  be  seen  about  the  pajtiiia. 

The  papilla  and  the  vessels  of  tlie   retina  are  normal. 

This  is  a  condition  that  is  met  with  rather  frequently  in  eyes  that  have 
suffered  from  iiiti  rst  itial  keratitis.  It  is  sometimes  to  be  seen  throughout  the 
entire  periphery,  sometimes  to  be  found  only  in  separate  circumscribed  areas. 


186 


Tab.  29. 


Fig.  53, 


PLATE  XXX 

Fig.  54.    Schematic  Pictures  of  Diseases  of  the  Chorioidal  Vessels 


Fig.  54.    Schematic  Pictures  of  Diseases  of  the  Chorioidal  Vessels 

(For  the  explanation  of  this  plate  see  page   168) 


188 


Tab.  30. 


QsaaaaacsfiaflDD 

<2  '•>        o"^     ^ 


^^^ft^':^  -^^^-^^^    %^l:;;::fe 


Fiu.  54. 


.      =»--       '  _  -  -_-•    <^-  -  r  Chorioid 


!•  Retina 


/ 


PLATE  XXXI 

Fig.  55.     The  So-called  Pepper  and  Salt  Fundus  of  Hereditary 

Syphilis 

Fig.  56.    Very  Severe  Chorioretinitis  Due  to  Hereditary  Syphilis, 
with  Atrophy  of  the  Optic  Nerve 


Fig.  55.     The  So-called  Pepper  and  Salt  Fundus  of  Hereditary 

Syphilis 

(Sec   page   175) 

The  papilla  and  tlie  vessels  ol'  the  ri'tina  are  normal.  The  density  "f  the 
pigment  epitluiiinn  varies  in  ditt'erent  parts  of  the  fundus.  In  some  ))laces 
it  hides  the  chorioid  completely,  in  other.s  the  markings  of  the  latter  arc 
plainly  visible.  A  j)atch  of  distinctly  sclerosed  vessels  is  to  be  seen  in  the 
vicinity  of  the  optic  nerve.  The  characteristic  feature  in  this  fundus  is  the 
presence  of  mnnerous  little,  roundish  depigmentations,  which  arc  often  sur- 
rounded  by   lialos   of  denser   pigment. 


Fig.  56.    Very  Severe  Chorioretinitis  Due  to  Hereditary  Syphilis, 
with  Atrophy  of  the  Optic  Nerve 

This  picture  was  taken   from  the  eye  of  a   hoy   l.'J  years  old. 

The  most  striking  feature  is  the  almo.st  total  absence  of  retinal  vessels, 
of  which  onlv  very  small,  sclerosed  traces  can  be  seen  in  the  innnediate  vicinity 
of  the  papilla. 

The  papilla  itself  is  perfectly  white.  On  account  of  the  total  absence 
of  an  excavation  and  the  invisibility  of  the  meshes  of  the  lamina  cribrosa, 
the  atrophy  must  be  supposed  to  be  of  inflammatory  oi'igin  in  spite  of  the 
fairly  sharp  margins.  Sharp  margins  are  rather  frequently  found  in  cases 
of  niuritic  atroj)hy  that  develop  iluring  childhood. 

Near  the  papilla  can  be  seen  some  sclerosed  vessels  of  the  clioi-ioid.  The 
rest  of  the  fundus  is  of  a  dirty  gray  color,  in  which  few  details  are  visible, 
with  the  exception  of  a  few  dots  of  pigment  and  some  bright  spots  that 
faintly  remind  one  of  the  depigmentations  si^en  in  the  preceding  picture. 
Some  of  the  vessels  of  the  chorioid  are  also  visible  in  the  uppermost  })art. 

This  boy  had  suffered  from  an  attack  of  syphilitic  meningitis  in  early 
childhood,  which  caused  an  optic  neuritis  with  a  subsequent  atrophy,  and  at 
the  same  time  the  serious  disease  of  the  vessels  of  the  retina  and  chorioid 
asserted  itself. 

The  vision  of  this  eye  naturally  was  nil. 


190 


Tab.  31. 


Fig;.  55. 


I'ig.  56. 


PLATE  XXXII 
Fig.  57.    Chorioretinitis  Due  to  Hereditary  Syphilis 


Fig.  57.    Chorioretinitis  Due  to  Hereditary  Syphilis 

Tliis  picture  presents  anotlier  type  of  hereditary  syphilis  of  tlie  eye. 

The  papilla  is  rather  paler  than  normal,  especially  in  its  temporal  half. 
The  arteries  of  the  retina  are  very  small.  Some  of  the  veins  of  the  retina 
have  well  marked  mantles  of  pigment  in  their  peripheral  portions. 

Only  a  few  spots  of  pigment  surrounded  by  bright  areola*  can  be  seen  in 
the  periphery. 

The  markings  of  the  chorioid  can  be  seen  very  plainly  in  the  periphery. 
This  is  because  the  pigment  epithelium  and  the  choriocapillaris  have  been 
destroyed  (sec  page  176). 


192 


Tab.  32. 


PLATE  XXXIII 

Fig.  58.    Chorioretinitis  Due  to  Hereditary  Syphilis,  with  Atrophy 

of  the  Optic  Nerve 


Fig.  58.    Chorioretinitis  Due  to  Hereditary  Syphilis,  with  Atrophy 

of  the  Optic  Nerve 

As  in  tln'  case  depicted  in  Fig.  56,  Hh'  condition  here  presented  was 
preceded  by  a  meningitis,  a  consequence  of  which  was  tlio  atropliy  of  the 
papilhi,  which  is  surrounded  b_v  a  very  distinct   ring  of  glia  tissue. 

The  vessels  of  the  retina  arc  very  small  and  drawn  out. 

The  entire  funilus  shows  a  iiigh  degree  of  depigmentation,  with  the  remains 
of   the    {)ignient    grouped   about    separate   roundish    foci,   whicli    call    to   mind 

Fig.  55. 

It  cannot  lie  determined  with  certainty  whether  the  crescentic  reddish  spot 
in  the  macuLa  is  a  hemorrhage,  or  a  deposit  of  pigment,  because  many  of  the 
small  spots  of  pigment  exhibit  a  reddish  tone  of  color. 


194 


Tab.  3»- 


Fig;.  5S. 


PLATE  XXXIV 

Fig.  59.     Early  Stage  of  Arteriosclerosis  of  the  Vessels  of  the 
Chorioid  in  the  Region  of  the  Macula 

Fig.  60.    Senile  Degeneration  of  the  Macula 

Fig.  61.    Senile  Degeneration  of  the  Macula 

Fig.  62.    Senile  Degeneration  of  the  Macula 


Fig.  59.     Early  Stage  of  Arteriosclerosis   of  the  Vessels  of  the 
Chorioid  in  the  Region  of  the  Macula 

(S(v   \mgv    lT(i) 

In  this  picture,  taken  from  tlic  eye  of  a  man  fiO  years  old,  some  of  the 
vessels  of  the  chorioid  can  be  sien  plainly  in  the  macula.  The  fundus  is 
otherwise  normal.  'I'lie  place  is  surrounded  hy  a  circle  of  very  minute  bright 
spots. 

Tile  explanation  of  this  picture  is  that  a  portion  of  the  pigment  epithe- 
lium has  !)een  caused  to  atro[)hy  by  a  disease  of  the  ciloriocapillaris,  and  tliat 
consi'([uen(  ly  the  rionnally  colored  large  vessels  of  the  chorioid  have  become 
visible. 

The   white   spots   are   due   to   colloid   deposits   on   the   viti'eous   lamella. 

The  vision  in  this  case  was  y^  of  the  normal. 

Fig.  60.    Senile  Degeneration  of  the  Macula 

(See  page   17()) 

In  this  case  also  some  large  vessels  of  the  chorioid  arc  visible,  with  a 
number  of  fine  points  of  pigment  mar  them;  otherwise  the  fundus  is  normal. 
Vision  was  reduced  to  ^s- 

The  {)igment  epithelium  of  tl-.e  retina  and  the  ciloriocapillaris  must  have 
been  destroved,  for  otherwise  the  markings  of  the  chorioid  could  not  be  seen. 

Fig.  61.    Senile  Degeneration  of  the  Macula 

(See   })age   17()) 

Another  form  of  degeneration  in  the  macula  is  shown  in  this  picture.  A 
number  of  very  minute,  bright  points  are  to  be  seen  lying  in  a  bed  of  pigment 
gramiles.  Some  areas  of  depigmentation  are  visible  in  the  peri()hery.  The 
])aj)illa  is  too  red  in  the  picture,  and  the  conus  is  too  white,  it  should  in  fact 
be  rather  yellow.  The  spot  of  pigment  is  a  portion  of  the  pigment  ring  and 
denotes  nothing  pathological. 

Fig.  62.    Senile  Degeneration  of  the  Macula 

(Sec  page  176) 

The  changes  in  this  picture  arc  similar  to,  but  grosser  than  those  seen 
in  Fig.  61.  The  papilla  is  surrounded  by  a  white  band  that  is  too  broad  to 
be  a  physiological  connective  tissue  ring.  It  must  be  su])posed  to  be  a  senile 
halo,  although  its  color  is  not  quite  right  for  this  condition.  The  pigmented 
edge  is  likewise  broader  than  the  physiological  pigment  ring,  and  must  be 
considered  to  be  jiathological. 

196 


Tab.  :H. 


Fig.  59. 


rig.  60. 


i  ]".  61 


hig.  02. 


PLATE  XXXV 

Fig.  63.     Finely  Pigmented  Fundus  of  Hereditary  Syphilis,  the 

So-called  Snuff  Fundus 

Fig.  64.    Sclerosis  of  the  Vessels  of  the  Chorioid  in  the  Region 

of  the  Macula 


Fig.  63.     Finely  Pigmented  Fundus  of  Hereditary  Syphilis,  the 

So-called  SnufF  Fundus 

(See  page   175) 

Tliis  is  till'  siiiifl'  fundus,  :\.  (iiK'ly  pigiuriilrd  tv])c  wliicli  is  met  with  in 
liei-editarv  svpiiilis,  in  addition  to  the  grossly  pitiincnti'd  one  shown  in  Fig.  53. 

Such  a  typical  and  distinctive  picture  as  the  one  depicted  lierc  is  seen 
comparatively   rarely,  but  a  less  pronounced  form  is  mot   with  very  often. 

Tlu'  papilla  and  retina  arc  intact,  the  chorioid  alone  presents  lesions, 
which  ai'e  seen  with  the  microscope  to  i)c  a  disease  of  tiie  choriocapillaris  with 
secondary  disturhancis  of  tiie  pigment,  and  manifest  themselvi^s  ophthalmo- 
scopicalij  as  finely  granular  heaps  of  pigment  and  round  foci  of  degeneration. 


Fig.  64.     Sclerosis  of  the  Vessels  of  the  Chorioid  in  the  Region 

of  the  Macula 

(Sec  page  178) 

This  could  also  be  called  a  senile  degeneration  of  the  macula  if  we  were 
not  accustomed  to  designate  by  this  term  sucii  insignificant  changes  as  those 
depicted  in  Figs.  59  to  62. 

The  fundus  is  of  the  tessellated  type,  so  tiiat  the  vessels  of  the  chorioid, 
with  the  deposits  of  pigment  between  tiiem,  are  plainly  visil)le  in  consequence 
of  the  thinness  of  the  ])igment  ej)ithelium.  The  vessels  of  the  chorioid  in  the 
region  of  the  macula  are  sclerosed,  i.e.,  their  wails  have  become  thickened. 
'I'lie  thickening  of  the  walls  is  so  great  in  places  that  a  cokunn  of  blood  is 
no  longer  visible  in  some  of  the  vessels,  while  only  a  slender  column  can  be 
seen  in  the  center  of  others. 

The  papilla  is  normal,  the  retinal  arteries  are  rather  small. 

The  reduction  of  vision  is  naturally  very  great  in  such  cases;  in  this  case 
the  patient  could  only  count  fingers  at  2  meters. 


198 


Tab.  35. 


Fie.  f>3. 


Fig.  64. 


PLATE  XXXVI 

Fig.  65.     Peripapillary  Sclerosis  of  the  Vessels  of  the  Chorioid 

Fig.   66.     Peripheral   Patch   of   Sclerosis   of   the  Vessels   of  the 

Chorioid 


Fig.  65.     Peripapillary  Sclerosis  of  the  Vessels  of  the  Chorioid 

(See  pages  39  and  178) 

Tlie  vicinity  of  the  papilla,  as  well  as  that  of  the  macula,  is  a  favorite 
place  for  sclerosis  to  attack  the  vessels  of  the  chorioid.  In  several  places 
the  vessels  may  tie  seen  to  he  wholly  obliterated,  while  in  others  they  are  only 
])artly   filled   with  blood. 


Fig.   66.     Peripheral   Patch   of   Sclerosis   of   the  Vessels   of   the 

Chorioid 

This  might  be  mistaken  at  first  glance  for  a  coloboma  of  the  ciiorioid  if 
the  intervascular  spaces  could  not  be  seen  so  plainly.  The  vessels  them- 
selves are  wholly  obliterated  and  invisible.  The  reason  why  they  still  seem 
to  be  present  is  that  the  pigment  which  is  normally  situated  between  them 
still  remains  visible  after  they  have  disappeared,  and  outline  the  empty  spaces 
left  by  them  (comjiare  with  Plate  XXX).  If  this  pigment  also  should 
disapj)ear  a  uniform  white  surface  would  be  left.  The  lumps  of  pigment  on 
the  margin  are  due  to  proliferations  of  pigment.  The  presence  of  newly 
formed  vessels  renders  it  very  probable  that  this  condition  was  one  of  inflam- 
matory origin  (see  page  104), 


200 


Tab.  3«. 


Fisi.  65. 


f-i".  tiO. 


PLATE  XXXVII 

Fig.  67.    Great  Sclerosis  of  the  Vessels  of  the  Chorioid,  and  Less 

of  Those  of  the  Retina 

Fig.  68.    Extreme  Sclerosis  of  the  Vessels  of  the  Chorioid 


Fig.  67.    Great  Sclerosis  of  the  Vessels  of  the  Chorioid,  and  Less 

of  Those  of  the  Retina 

(Sec    page    ISO) 

All  of  the  vessels  of  the  cliorioiil  that  arc  \isii)l('  are  sclerosed,  and  only 
a  few  of  thuiii  contain  slender  colunnis  of  blood.  The  pigment  epitheliinn 
must  have  been  destro^'ed  very  extensively;  the  heaping  up  of  pigment  in 
various  places  is  in  harmony  with  such  a  destruction.  The  papilla  is  rather 
]).iler  than  normal  (see  page  .55),  and  the  vcssejs  of  the  retina,  particularly 
the  arteries,  are  evidently  contracted  (see  page  98). 


Fig.  68.    Extreme  Sclerosis  of  the  Vessels  of  the  Chorioid 

(See  page  176) 

The  sclerosis  is  still  more  extensive  in  this  case,  and  has  reached  a  nmch 
greater  intensity.  While  the  intervascular  pigment  of  the  chorioid  was  pre- 
served throughout  its  normal  extent  in  the  jireceding  case,  in  this  one  it  is 
so  atrophic  that  the  time  seems  to  he  not  far  distant  when  the  entire  fundus 
will  he  transformed  into  a  white  surface.  The  region  of  the  macula  shows 
a  trace  of  pigment  epithelium,  vet  this  also  is  changed.  The  papilla  and 
the  vessels  of  the  retina  are  normal. 

This  vision  was  comparatively  good,  ^(i  of  the  normal,  hut  the  visual  field 
was  concentrically  contracted  to  an  extremely  small  trace. 

This  case  was  met  with  in  a  girl  13  years  of  age  who  had  hereditary 
syphilis.     Her  sister  had  a  similar  condition. 


202 


Tab.  37. 


f-'ig.  OS. 


PLATE  XXXVIII 
Fig.  69.    Chorioretinitis  Albuminurica 


Fig.  69.    Chorioretinitis  Albuminurica 

(See  page   lli'S) 

A  picture  similar  to  the  preceding  one  may  be  produced  by  renal  disease. 
In  such  cases,  which  are  pretty  rare,  the  signs  of  inflammation  on  the  papilla 
and  in  the  retina  can  scarcely  be  missed.  In  the  present  case  the  nasal  side 
of  the  papilla  is  distinctly  hazy.  The  retina  shows  plain  signs  of  oedema  by 
the  haziness  of  its  vessels,  and  contains  some  hemorrhages. 

The  vision  is  greatly  impaired  in  such  a  case;  in  this  patient  it  was 
reduced  to  counting  fingers  at  2  meters. 


204 


Tab.  38. 


Fig.  6Q. 


PLATE  XXXIX 

Fig.  70.     High  Myopia;  Temporal  Staphyloma;   Change  in  the 

Macula 

Fig.  71.    High  Myopia;  Circular  Staphyloma;  Sclerosed  Vessels 

of  the  Chorioid 


Fig.  70.     High  Myopia;  Temporal  Staphyloma;   Change  in  the 

Macula 

(Seepages  .'J7  imd  177) 

The  papilla,  which  is  vertically  oval  in  this  case,  has  a  strikingly  indis- 
tinct temporal  margin;  it  seems  to  blend  at  this  place  with  the  staphyloma, 
which  is  situated  altogether  on  its  temporal  side.  See  page  .'38  for  the  rela- 
tions l)etween  the  form  of  the  papilla  and  that  of  the  staphyloma.  The  latter 
is  divided  into  2  portions,  one  situated  near  the  papilla,  in  wiiich  piimtatc 
markings  can  be  seen,  the  other  farther  away,  which  is  pure  white.  The 
punctate  markings  are  due  to  traces  of  chorioidal  pigment  that  have  been 
left  after  destruction  of  the  vessels  of  the  chorioid  (see  page  37). 

The  vessels  of  the  chorioid  can  be  seen  plainly  in  this  very  pale  fundus, 
as  well  as  some  chorioidal  hemorrhages  to  the  nasal  side  of  the  papilla.  In 
the  region  of  the  macula  is  a  maze  of  white  cords,  which  are  explained  by 
some  as  sclerosed  vessels  of  the  chorioid,  by  others  as  fissures  in  the  pigment 
epithelium   (see  page  37). 


Fig.  71.    High  Myopia;  Circular  Staphyloma;  Sclerosed  Vessels 

of  the  Chorioid 

(See  pages  37  and  177) 

This  picture  presents  all  of  the  characteristics  of  a  myopic  eye;  staphy- 
loma, pale  fundus,  stretched  vessels  of  the  retina,  sclerosed  ones  of  the  chori- 
oid. The  papilla  is  normal,  and  is  surrounded  by  a  circular  staphyloma,  in 
the  nasal  side  of  which  some  traces  of  chorioidal  pigment  and  one  normal 
chorioidal  vessel  can  be  seen;  all  the  other  details  have  been  destroyed.  The 
rest  of  the  chorioidal  vessels  can  be  seen  very  well  in  the  pale  fundus.  The 
region  of  the  macula,  which  is  rather  richly  pigmented,  shows  a  peculiar  maze 
of  white  cords  with  little  processes  that  remind  one  of  the  frosted  branches 
of  a  tree.  Some  dots  of  pigment  and  some  rather  superficial  depigmentations 
are  also  to  be  seen.  It  cannot  be  told  with  certainty  whether  all  of  the  white 
cords  are  sclerosed  vessels  of  the  chorioid,  or  a  part  of  them  are  due  to  fissures 
in  the  pigment  epithelium  (see  page  37). 

The  myopia  in  this  case  was  12  diopters. 


206 


Tab.  :J9. 


Fig.  70. 


-ig.  i\ 


PLATE  XL 

Fig.   72.     High   Myopia  with   Circular  Staphyloma   and   a  Very 
Great  Change  in  the  Macula 

Fig.  73.     High  Myopia  with  a  So-called  Staphyloma  Verum 


Fig.   72.      High   Myopia   with   Circular  Staphyloma   and   a   Very 
Great  Change  in  the  Macula 

(Sec  pages  .'57  aiul  182) 

Tlu'  I'uiulus  is  Vfi'V  pale,  and  soiiir  of  the  vessels  of  the  ehoriold  can  he 
seen  (jiiitt'  plainly,  as  often  ha])])(iis  in  myopia.  This  is  hecaiise  of  the 
stretching  of  the  layer  of  pigment  epithelium.  The  vessel.s  of  the  retina  arc 
extremely  drawn  out  and  are  smaller  than  normal.  The  papilla  is  surrounded 
by  a  circular  staphyloma  which  is  broadest  upward  and  outwaid.  A  very 
careful  examination  re\eals  some  remains  of  ehoi-ioidal  pigment,  uhicli  is  the 
last  trace  of  the  ehorioid  that  has  vuidergone  atropiiy.  The  staphyloma  is 
surrounded  by  a  more  or  less  strongly  pigmented  zone.  Some  small  atrophic 
spots  may  be  seen  to  its  nasal  side.  The  region  of  the  macula  is  occu])ied  by 
a  large,  kidney-shaptd  spot,  measuring  2X21/^  papillary  diameters,  in  the 
liilus  of  which  is  a  spot  as  large  as  the  papilla,  composed  of  numerous  dots 
of  pigment. 

Above  and  below  the  latter  lie  several  smaller  spots  of  pigment,  which 
are  to  be  distinguished  from  the  remaining  chorioidal  pigment  by  the  intensity 
of  their  color.  Sclerosed  yessels  of  the  ehorioid,  intermixed  with  white  and 
black  spots,  lie  to  both  the  temporal  and  the  nasal  sides  of  this  principal 
spot.  The  vision  in  this  casi-  was  counting  fingers  at  2  meters  with  the 
correcting  glass,  — 1(5  U  sph.  ^  — 2  D  cyl. 

Fig.  73.     High  Myopia  with  a  So-called  Staphyloma  Verum 

(  See   })age   2() ) 

The  papilla  appears  to  be  remarkably  small,  an  optical  illusion  caused 
by  the  high  degree  of  myopia  (see  page  17).  It  is  surrounded  by  a  circular 
staphyloma,  which  indicates  tliat  the  vicinity  of  the  papilla  is  pouched  out 
rather  luiiformly  (see  page  38  concerning  the  form  of  the  staphyloma). 
Parallel  to  the  nasal  margin  of  the  papilla  are  to  be  seen  one  large  and  two 
small  gray,  or  rcdtlish  gray,  curved  lines,  in  the  region  of  which  the  vessels 
of  the  retina  plainly  bend.  They  are  shadows  cast  by  the  margins  of  the 
protrusion  of  the  posterior  pole,  sclerectasia,  and  consequently  this  has  been 
termed  staphyloma  verum.  Throughout  its  area  the  fundus  is  considerably 
brighter  than  it  is  elsewhere,  because  of  the  great  stretching  of  the  pigment 
epithelium.  The  vessels  are  extremely  small,  partly  because  of  the  stretching, 
partly  because  of  an  optical  illusion.  The  arteries  are  drawn  out,  the  veins 
are  very  tortuous,  an  unusual  symptom  in  myopia,  which  may  perhaps  indi- 
cate a  threatened  detachment  of  the  retina. 

Part  of  the  vessels  of  the  ehorioid  are  very  clearly  visible  and  some  con- 
verge toward  the  papilla  (compare  with  Fig.  3).  In  the  region  of  the  macula 
these  vessels  are  distinctly  sclerosed  in  places,  a  preliminary  stage  of  a 
greater  change  in  the  macula,  such  as  may  be  seen,  for  example,  in  Fig.  71. 

The  myqpia  in  this  case  was  ap])roximately  35  diopters. 

208 


Tab.  40. 


t^iii.  72. 


Fi".  73. 


PLATE  XLI 

Fig.  74.     Atrophic  Spots  in  the  Chorioid  with  Plainly  Sclerosed 

Vessels 

Fig.  75.     Neuritic  Atrophy  of  the  Optic  Nerve;  Atrophic  Spot  in 

the  Periphery 


Fig.  74.     Atrophic  Spots  in  the  Chorioid  with  Plainly  Sclerosed 

Vessels 

(See  page  180) 

Two  .sli;ir])ly  circumscribod  spots  of  atrophy  arc  to  be  seen  in  an  otlier- 
wise  normal  fundus,  one  in,  the  other  beh)w  tiic  macuhi.  The  lower  one 
resembles  very  closely  one  of  the  schematic  drawings  on  Plate  XXX.  Scler- 
osed chorioidal  vessels  are  to  be  seen  with  some  pigment  between  them,  hut 
the  latter  has  begun  to  disappear,  so  it  is  to  be  expected  that  the  spot  will 
be  perfect!}'  white  within  a  short  time,  as  the  sclera  will  then  be  laid  bare. 
Two  of  the  vessels  still  contain  blood,  liut  the  others  are  completely  sclerosed. 
The  spot  is  bordered  by  a  ring  of  pigment. 

The  upper  spot,  which  is  due  to  the  same  cause  as  the  lower,  exhibits  an 
abundant  development  of  pigment,  which  forms  a  mass  so  shaped  as  to  divide 
the  spot  into  ■!  smaller  ones.  The  pigment  epithelium  has  begun  to  become 
lighter  in  its  neighborhood. 

As  soon  as  sclerosed  vessels  are  noticed  in  the  fundus  we  have  to  think 
chiefly  of  arteriosclerosis,  syphilis,  or  nephritis  as  the  cause,  in  the  absence 
of  niyoj)ia.     Syphilis  was  the  cause  in  this  case. 


Fig.  75.    Neuritic  Atrophy  of  the  Optic  Nerve;  Atrophic  Spot  in 

the  Periphery 

The  atrophy  of  the  papilla  is  shown  to  be  neuritic  by  the  indistinct  mar- 
gins and  the  great  haziness  of  its  surroundings.  The  latter  indicates  that  the 
retina  was  involved  to  quite  a  considerable  degree,  and  that  the  case  was  a 
very  severe  one  of  neuroretinitis.  This  corresponds  to  the  actual  conditions, 
for  a  choked  disk  preceded  the  atrophy  and  was  caused  by  a  gumma  of  the 
orbital  portion  of  the  optic  nerve.  The  absence  of  any  sheathing  of  the 
retinal  vessels  is  noticeable.  The  pigment  epithelium  is  denser  in  the  upper 
part  of  the  fundus  than  in  the  lower,  so  that  the  markings  of  the  chorioid 
arc  not  as  clearly  visible  above,  but  otherwise  the  rest  of  tlie  fundus  is  normal, 
except  for  a  peculiar  change  to  be  seen  in  the  extreme  periphery,  where  a 
whitisli  spot  with  sharp  outlines  stands  out  amid  normal  surroundings.  It 
is  formed  from  more  or  less  sclerosed  vessels  of  the  chorioid,  between  which 
traces  of  the  pigment  can  still  be  seen.  It  is  bordered  by  a  beautiful  ring  of 
pigment.  See  Plate  XXX  for  the  pathology.  The  lesion  in  this  case  was  due 
to  a  quite  circumscribed  syphilitic  disease  of  the  vessels. 


210 


Tab.  41. 


Fit:.  74. 


•ig.  (3. 


PLATE  XLII 

Fig.   76.     Extensive   So-called   Chorioretinitis   Disseminata  with 
Scleroses  of  the  Vessels  of  the  Chorioid 

Fig.  77.    So-called  Chorioretinitis  Disseminata  with  Scleroses  of 
the  Vessels  of  the  Chorioid 


Fig.   76.     Extensive   So-called   Chorioretinitis   Disseminata   with 
Scleroses  of  the  Vessels  of  the  Chorioid 

The  fundus  shows  serious  changes  througliout  its  entire  extent,  so  fur  us 
it  is  depicted  here,  partly  by  jiatches  of  ilecoloratioii,  partly  by  heaps  of 
pigment. 

I'he  papilla  and  the  vessels  of  the  retina  are  normal;  the  latter  pass 
smoothly  over  the  lesions,  hence  the  inner  layers  of  the  retina  are  likewise 
normal,  and  the  lesions  must  lie  in  the  outer  layers  of  the  retina  and  in  the 
chorioid ;  they  are  changes  in  the  pigment  epithelium  and  scleroses  of  the 
vessels. 

The  larger  part  of  the  fundus  to  the  nasal  side  of  the  jiapilla  approaches 
the  normal,  yet,  even  in  this  part,  lumps  of  pigment  and  sheathings  of  the 
vessels  can  be  seen.  Not  a  normal  vessel  of  the  chorioid  is  visible  any  longer 
in  the  rest  of  the  fundus ;  above  there  are  some  vessels  that  are  filled  with 
blood,  but  even  these  are  sheathed.  Where  the  pigment  epithelium  between 
them  has  already  been  lost  pure  white  places  are  to  be  seen,  produced  by 
the  sclera  covered  with  remnants  of  tissue.  A  disappearance  of  the  pigment 
epithelium  of  the  retina  is  the  first  requirement  in  order  that  these  details 
of  the  sclera  may  become  visible,  but  when  the  pigment  leaves  it  settles  else- 
where and  gives  rise  to  pictures  that  resemble  this  one.  Of  the  three  causes 
of  disseminated  chorioretinitis  with  vascular  sclerosis,  syphilis,  arteriosclerosis 
and  nephritis,  the  first  was  the  agent  in  this  case. 


Fig.  77.     So-called  Chorioretinitis  Disseminata  with  Scleroses  of 
the  Vessels  of  the  Chorioid 

This  picture  exhibits  changes  that  are  quite  similar  to  those  shown  in  the 
preceding  one,  so  much  so  that  a  separate  description  is  not  needed  (see 
page  182). 

The  cause  in  this  case  was  a  nephritis  gravidarum.  The  symptoms  ap- 
peared chiefly  in  one  eye  during  the  first  pregnancy  and  became  much  worse 
during  the  second.  As  the  second  eye  was  seriously  affected  in  a  third 
pregnancy  premature  labor  was  induced,  after  which  both  the  albuminuria 
and  the  changes  in  the  eye  retrogressed.  When  the  patient  became  pregnant 
a  fourth  time  an  abortion  was  induced  at  once. 


212 


Tab.  42. 


Fig.  76. 


Fig.  77. 


PLATE  XLIII 
Fig.  78.     Chorioretinitis  Tuberculosa 


Fig.  78.     Chorioretinitis  Tuberculosa 

(See  page  181^ 

This  picture  sliows  tlie  typical  condition  of  a  tuberculosis  of  the  chorioid 
that  is  fresh  in  some  places,  old  in  others. 

The  fresh  tubercles  cannot  be  seen,  they  make  themselves  manifest  bv 
the  effect  they  produce  on  the  retina;  for  tlio  little,  circumscribed  spots  are 
islands  of  retinal  oedema.  It  can  be  perceived  that  these  are  raised  wherever 
a  vessel  of  the  retina  passes  over  one;  the  vessel  exhibits  a  wavy  course  at 
that  place,  as  well  as  the  loss  of  the  light  streak  in  the  depressions,  charac- 
teristic of  changes  of  level.     The  oedematous  places  are  also  a  little  hazy. 

Part  of  the  older  places  are  marked  by  depigmentations,  part  by  accumu- 
lations of  pigment.  The  wreathlike  appearance  is  produced  by  the  confluence 
of  various  individual  foci. 

An  im})ortant  point  to  be  noted  is  that  no  vascular  changes  are  to  be 
seen  in  the  picture. 


314 


Tab.  4». 


Fig.  78. 


PLATE  XLIV 
Fig.  79.    Chorioretinitis  Tuberculosa 


Fig.  79.    Chorioretinitis  Tuberculosa 

(See  page  181) 

Tliis  picture  is  one  of  an  old  tuberculosis.  The  hritrht  spots  arc,  almost 
without  exception,  produced  by  the  confluence  of  individual  tubercles.  In 
the  vicinity  of  these  spots  is  to  be  seen  a  depigmentation  that  looks  "as  though 
a  chemical  fluid  had  been  poured  over  them."  The  heaping  of  pigment  in 
the  vicinity  is  considerably  less  than  in  diseases  of  the  chorioid  that  accom- 
pany sclerosis  of  the  vessels.  Pigment  gradually  migrates  into  the  retina  as 
it  liecomes  atrophic   (compare  with  Plate  XXX). 

The  vessels  of  the  retina  and  the  papilla  are  normal. 


216 


Tab.  44. 


n-.  79. 


PLATE  XLV 

Fig.  80.     Healed  Inflammatory    (Tuberculous?)    Spot  In  the 

Macula 

Fig.  81.    Fundus  of  the  Eye  in  Acute  Miliary  Tuberculosis 


Fig.  80.     Healed   Inflammatory    (Tuberculous?)    Spot  in  the 

Macula 

(Sec  page  181) 

An  inflammatory  spot  about  twice  as  largo  as  the  papilla  liad  formed  in 
the  macula  of  a  girl  14  years  old.  Its  etiology  was  obscure,  but  there  were 
no  signs  of  accjuired  or  lurcditary  sypiiilis.  ]V<ix.\iriii(iiin\s  test  proved  nega- 
tive, the  tuberculin  reaction  on  the  contrary  was  ])ositive.  The  a'dema  of  the 
retina  disappeared  under  tre;itment  witli  tuberculin,  and  the  condition  was 
left  which  is  shown  in  the  picture.  .\  white  spot  smaller  than  the  papilla  is 
to  be  seen,  surrounded  by  a  dark  ring,  and  then  by  a  lighter  one  in  which  the 
pigmentation  is  less.  In  the  neighborhood  of  the  spot  are  three  heaps  of 
pigment  of  various  shapes,  but  on  the  whole  roundish,  each  surrounded  by  a. 
brighter  ring. 

Fig.  81.    Fundus  of  the  Eye  in  Acute  Miliary  Tuberculosis 

(See  pages  129  and  132) 

The  margins  of  the  papilla  are  very  ha/y,  tiie  \eins  are  dilated,  signs  of 
an  optic  neuritis.  Three  light  gray  spots  are  to  be  seen  in  the  uniformly 
colored  fundus ;  one  round  and  with  sharply  defined  edges,  the  others  elon- 
gated and  with  indistinct  margins.  The  elongated  spots  have  roundish,  brighter 
nuclei,  with  a  faded  wing  on  each  side.  The  bright  spots  are  tubercles  in  tlie 
chorioid,  or,  rather,  patches  of  a'dema  in  the  retina  that  the  tubercles  excite 
by  their  presence. 

Tubercles  are  particularly  apt  to  lie  at  the  posterior  pole  of  the  eye,  and 
are  almost  always  associated  with  an  optic  neuritis,  which  is  caused  by  a 
meningitis. 

This  picture  is  from  the  eye  of  a  boy  7  years  old,  who  died  of  tuberculosis 
two  days  after  it  was  taken. 


218 


Tab.  45. 


Fig.  80. 


1-ig.  SI. 


PLATE  XLVI 

Fig.  82.     Extensive  Rupture  of  the  Chorioid  with  Development 
of  Connective  Tissue  in  Places 

Fig.  83.    Rupture  of  the  Chorioid 


Fig.  82.     Extensive  Rupture  of  the  Chorioid  with  Development 
of  Connective  Tissue  in  Places 

(See  page  182)    • 

This  patient  liad  received  a  blow  on  tiie  eye  from  a  broken  belt.  After 
the  innnciise  hemorrhage  into  the  vitreous  liad  been  absorbed  two  hirge  white 
spots  could  l)c  seen  at  the  place  where  t!ie  injury  was  roci'ived.  One  was  a 
rupture  of  the  cliorioid  witli  two  points  jutting  to  tiie  riglit  and  the  left. 
Traces  of  some  vessels  can  be  seen  in  tlie  rupture.  The  entire  place  has  an 
edge  of  pigment. 

While  the  color  of  this  spot  is  a  light  yellow,  that  of  the  other  is  rather 
bluish.  Dots  of  pigment  are  abundant,  both  in  the  spot  itself  and  in  its 
vicinity.  A  distinct  parallactic  movement  I'ould  be  produced  by  moving  the. 
lens  held  in  front  of  the  ophthalmoscope.  Close  to  this  spot  a  smaller  one 
is  to  be  seen. 

Both  of  these  spots  are  to  be  regarded  as  pure  ru])tures  of  the  chorioid, 
while  the  one  between  them  shows  distinct  signs  of  a  proliferation  of  con- 
nective tissue,  which  must  be  considered  as  a  process  of  healing. 

These  ruptures  of  the  chorioid  at  the  place  of  impact  are  seen  more  rarely 
than  the  indirect  rupture  shown  in  the  next  picture. 


Fig.  83.    Rupture  of  the  Chorioid 

(See  pages  120  and  178) 

A  ■white  crescent  can  bo  seen  21/2  ^-  D.  from  the  papilla,  to  the  margin 
of  which  it  is  parallel.  The  retinal  vessels  pass  smoothly  over  its  upper  part, 
but  make  a  little  bend  as  they  pass  over  its  lower  portion,  perhaps  on  account 
of  a  commencing  development  of  connective  tissue.  In  the  middle  of  the 
crescent  is  a  little  reddish  spot,  which  may  be  either  a  hemorrhage,  or  a  tuft 
of  vessels.     Its  margins  are  distinctly  pigmented. 

Such  ruptures  of  the  chorioid,  which  often  leave  the  retina  intact,  as  it  is 
more  clastic,  are  the  consequences  of  severe  blows  on  the  anterior  part  of 
the  eye.     In  this  case  the  cause  was  a  blow  with  a  billiard  cue. 

The  effect  on  the  vision  varies  according  to  the  degree  of  injury  to  the 
retina  and  the  position  of  the  rupture.  If  the  latter  lies  between  the  papilla 
and  the  macula,  if  the  retina  is  torn,  or  if  the  rupture  extends  directly 
through  the  macula,  vision  will  be  badly  impaired.  In  other  cases  it  is 
hardly  affected. 


220 


Tab.  4«. 


Fig.  83. 


PLATE  XLVII 

Fig.  84.    Coloboma  of  the  Chorioid 
Fig.  85.     Extensive  Coloboma  of  the  Chorioid 


Fig.  84.    Coloboma  of  the  Chorioid 

(See  page  178) 

Above  tlie  papilla  in  the  inverted  image,  therefore  in  reality  below,  is  a 
large,  slate  gray  surface  which  has  on  one  side  a  rather  brownish  tone.  It 
has  a  broad  edge  of  pigment.  Within  the  surface,  over  which  the  vessels  of 
tiie  retina  pass  smoothly,  are  to  be  seen  several  bright  stripes  which  are 
interpreted  as  folds.  Some  scleral  vessels,  twisted  like  corkscrews,  enliven  the 
picture  farther  in.     The  papilla  and  its  surroundings  are  normal. 

The  vision  depends  on  the  extent  to  which  the  retina  is  involved;  some- 
times a  defect  is  found  in  the  visual  field  that  corresponds  to  this  place. 


Fig.  85.     Extensive  Coloboma  of  the  Chorioid 

The  coloboma,  whicli  in  the  preceding  case  stopped  at  some  distance  from 
the  papilla,  extends  in  this  one  above  the  entrance  of  the  optic  nerve,  so  that 
the  disk  lies  in  its  area.     The  scleral  vessels  are  very  numerous. 

In  the  middle  of  the  coloboma  is  a  roundish  spot,  the  margins  of  which 
shift  over  its  center  when  the  observer  moves  the  lens  held  in  front  of  the 
eye.  Hence  there  is  at  this  place  a  depression,  a  so-called  "sclerectasia." 
Some  granules  of  pigment  are  scattered  over  the  coloboma. 

The  rest  of  the  fundus  is  of  an  albinotic  character  and  so  contrasts  with 
those  of  the  preceding  cases. 

Such  colobomata  are  congenital  and  are  not  progressive. 


222 


Tab.  47. 


Fig.  84. 


Fig.  Sd. 


PLATE  XLVIII 
Fig.  86.    Normal  Fundus  of  a  Rabbit 


Fig.  86.    Normal  Fundus  of  a  Rabbit 

Tlie  papilla  is  transversely  oval  and  is  plainly  excavated,  or  surrounded 
by  a  wall  over  which  the  vessels  of  the  retina  rise.  To  the  right  and  left 
of  the  papilla  are  two  enormous  white  wings  of  medullated  nerve  fibers  in 
which  the  vessels  of  the  retina  course. 

The  rest  of  the  fundus  is  uniformly  colored. 


THE  COPYRIGHTS  OF  THIS  BOOK,  IN  ALL  ENGLISH-SPEAKING  COUNTRIES,  ARE 
OWNED  BY  REBMAN  COMPANY,  NEW  YORK 


224 


Tab.  48. 


Fio;.  86. 


Index 


Abscess  of  the  brain,  7-2,  78 
extradural,   77,  90 
orbit,   81 
Accessory  sinuses,  changes  in,  7,  79 

dilatation  of  veins  and  arteries,  100 
neuritis,  59,  7i,  78,  79 
Accommodation,  paresis   of,   7(i 
Accompanying  white  stripes,  see  Chorioid,  57 
Albinism,  partial,  39,  48,  177 
Albinotic   fundus,   -25,  30 
Albuminuria,  72,  79,  88,  118,   13-1,   170 
changes  in   the  vessels,   100,   118,   \22,  2\2 
detachment,  151 
neuroretinitis,   130 
retinal  hemorrhage,  119,  i22 
Alcohol,  59,  79,  99 
Ampliobia,  39 

Anemia,   retinal  hemorrhages,  118,  119 
retinal  vessels,  102 
retinitis,   135 
Aneurism,  aorta,  107 
carotid,    i07 
of  the  brain,  81 
Anteater,  53 
Apoplexy  of  the  brain,  118,  153 

sanguinea,  117,  122 
Armadillo,  eye  of,  53 
Arsenic,  59 

Arterial  pulse,  23,  106 

Arteriosclerosis.  39,   55,   72,   118,   129,   153,   171, 
176.  212 
changes  in  retinal  vessels,  100,  150,  202 
detachment,  151 
neuritis,  76,  88 
Artery,  central,   occlusion,  55,  68    82.  99,   103, 
107,  127,  146,  153,  158 
ciliary,  167 
cilioretinal,  23,  44 
ophthalmic,  15 
Astigmatism,  39,  71 
Atoxyl,  59 

Atrophy  of  optic  nerve,  51 
arteriosclerosis,  52,   54 
choked   disk,  51,  57,  64 
differential  diagnosis,  52 
glaucomatous,  52,  54,  66 
gray,  52,  62,  72 

interruption  of  conduction,  52,  62 
neuritic,  52,  57,  64,   103,  190,  210 
nutritional,  52,  55 
occlusion  of  arteries,  52,  55,  68 
partial,  52.  58,  68 

retinitis  pl(.mentosa,  52.  58,  99,  184 
simple,  52,  53   [also  gray] 
syphilis,  acquired,  53 
'  congenital,  76,  190,  194 
total,  52 
tuberculosis,  76 
white,  53 
Auto-intoxications,  59 


Barlow's  disease,  chorioidal  hemorrhages,  119 

Berlin's  opacity,   156 
Bisulphide  of  carbon,  59 
Blooci,  diseases  of,   119 
Blue  blindness,  149,  151 
Brain,  abscess,  72,  77,  81 

choked  disk,  81 

tumors,  64,  81,  94,  101 
B  right's  disease,  see  Albuminuria 
Bu]ihthalmos,  182 


Cachexia,  cancerous,  119 

Cataract,  operation,  detachment  of  chorioid,  181 
Central   artery,  see   Artcrv,  central 
Cherry  red  spot,  73,  119,  150,  158 
Chiasm,  gumma,  53 
Chlorosis,  82,  102,  119 

Choked  disk,   15,  24,  79,  92,  101,  102,  120,  130 
albuminuric,  see  Neuritis 
atrophy,  see  Atrophy  of  Optic  Nerve 
bilateral,  80 

chorioidal  vessels,  100,  104,  105 
degeneration  of  chorioid,  91,  136 
differential  diagnosis,   73 
new  formation  of  vessels,  80,  81,  94 
unilateral,  80 
Cholesterin,  130 
Choriocapillaries,  113,  167.  168 
degeneration  of.  127,  169,  176 
Chorioid,  anatomy,  167 

atrophic  spots  without  visible  changes  in  the 
vessels,  180 
with  visible   changes   in   the  vessels,   ISO, 
188,  198,  200,  202,  206,  208,  210 
atrophy,  peri))apillary,  33,  ;{9,  46,  177,  200 
diseases,  about  the  optic  nerve.  177 
aliiuniinuria.  133,  180.  204,  212 
arteriosclerosis,  54,  180 
eolohoma,  33,  174,  177,  222 
diabetes,  181 

differences   of  level,   173,   181 
etiology.  168 
form  of,  173 
fresh  spots,  179 
in  periphery,  173 
malaria,    181 
oedema  of  retina,  149 
position.  172 
prognosis,  153 
region  of  macula,  176 
ruptures.   173,   178.  200 

sclerosis.  37,  46.  153,  171,  173,  181.  19S,  etc. 
svphilis.    180.    181 
tuberculosis,  179,  180 
tumors,  152,  162,  173,  181 
N'cssels,  25 
hemorrhages,  119 

proliferation  of  connective  tissue,  182,  220 
Chorioidal  ring,  18 


225 


226 


Cluiriii-rctiiiiti>,    179 
iilliiiininiirica,  ^04< 
ilisseniiiKita,  179,  2\2 
pignifiito.sa,  58,  99,  l(i8,  ITl,  184 

sei'oiithiry,  175,  181 
])r()lit('r:n',s,    17;},    18J 
.syiM]>.itlictic.  1J7,  118 
svi'liilitic,   .« ('   .'Svjiliilis 
■  confifiiital,  175,   18(i,  190,  191,  198 
tuberculous,  179,  -'U,  -'Hi 
Ciliary  vessels,  1()7 
Cilio-retinal  vessels,  33 
Circulus  arteriosus  iri<lis,  108 

nervi  optiei,  1(>7 
Cocain,  11 

Coiobonia,  see  Chorioid 
Commotio  retinae,  73 

Connective     tissue,     proliferation     of,     in     the 
diorioitl,  18J,  )iJO 
in  tlie  retina,  lOJ,  105,  131 
in  tile  retinal  vessels,  1U3,  105 
ring,  IS 
Contraction,  concentric,  51 
Conns    in   atro|iliic   |>a]>illa,   51 
inferior.  33,  39.   18 
temporalis.  3:i,  31.   H 
Cornea.  o]>acities,  73,  170 

reflexes  of,  'J 
Cyanosis,  101 
Cvsticercus,  81 


Depiginentation  of   tlie  <'liorioi(l,   168,   175 
Detaclinient  of  the  chorioid,   181 
retina.  73.  lU(i.  157.  KiO 
alliuniinuric,   133.   1 10,  15-2 
funnel-sha])eil,    153 
gibbous,  15J,  l&j 
tumor,  153,   163 
Diabetes,  59,  73,  77,  79,  139,  134,  154 
clianges  in  vessels  in  chorioi<l,  118 
hemorrhages  of  cliorioid,  118 
neuroretinitis,   135,  143 
Differential   diagnosis   in   changes   of   chorioid, 
173 
atrophies,  53 
changes  in   retina,  113 
changes  in  retinal  vessels,  98 
conus  staphyloma,  37 
crescents  of  o))tie  nerve,  33 
glaucomatous,  physiologic  excavation,  56 
medullary  nerve  fibers,  138 
neuritis.  73 

retinal   hemorrhages,   118 
retinal  o|)acity,  119 
retino-cborioidal  spots,  135 
retino-chorioidal  vessels,  35 
white  spots   (anatomv),  138 
(etiology).    131 
Diphtheria,  neuritis,  73 

crescents,  excavations,  34 
Diplopia,  76 

Eclampsia,  134 
Embolism,   101 
Emphysema,   101 
Endarteritis  proliferans,  158 
Ergotin,  99 
Excavation,  see  Atrophy 

atrophic,  53 

glaucomatous,  55,  66 


Excavation,    normal,    19,   56 
Exudates   of   chorioidal   vessels,    103,    130,   134, 
116 

Fever,  100 
Eilix  mas,  59 
Foreign  bodies,  118,  134 
Fovea,  36,   113 
Foveal  reflex,  3() 
Fuiulus,  albinotie,  35,  30 

color,  31' 

lesions,  [)lace,  10 
size,  11 

normal  types,  24,  28,  30 

])epper  and  salt,  175,  198 

snutl",   75 

stij)pled,  34,  38 

tessellated,  25,  38 

Glands  of  vitreous  lamella,  127,  148,  175 
Glaucoma,  14,  23,  40,  5-2,  57,  66,  120 

arterial  |)ulse,  107 

.secondary,  101 
Glauconuitous  atrophy,  14 

excavation,  14 

halo,  14 
Glia,  i)roliferation,  58,  103 
Glioma  retina%  50.  153,  164 
Gunujia  cerebral,  81,  83 

ill  chorioid,   181 

retinal,   83 

Habitus  a))0]ileeticus,  100 
lla'moiibilia,   119 
JJaiU's  charts,  59,  80 
Halo,  14,  33,  40 

glaucomatous,  55,  66 

senile,   10,  196 
Heart  disease,  71.  101,  107,  153 
Hedgehog,  eye  of,  53 
Hemeralopia",  174,  184 
Heniiaiioi)sia,  54,  81 
Hemorrhages,   119,   149 

atrophy  of  optic  nerve,  100 

chorioid,  119 

retina,  118 

subdural,  83 
Hemorrhagic  diathesis,  119 
Heiile's  laver,   130 
Herftell's  lamp,  152,  163 
H(«uatro|)ia.  11 
Horse,  eve  of,  41 
Hydroce'|)halus,  53,  81 
Hy])eraemia  of  retina,  101 
Hypernietro])ia,  71 

retinal  vessels,  course  of,  25,  105 
Hy]>oi)hysis,  81 

Image,  inverted,  3 

upright,  8 
Infectious  diseases,  119 
Influenza  of  retina,  119 
Injuries,  33,   71 

iirain.  81 

elicn-ioid.    176,   183 

commotio,   retinal,  see  Commotio 

detachment,  151 

oiitic  nerve,  54,  63,  83 

retina.   104,  118,  134,  151 

ruj)ture  of  chorioid,  330 
Interrujition  of  conductivity,  54 


227 


Intervasciilar  spaces,  25,  28 
Intoxications,  52,  59,  79 
Iridocyclitis,  71 
Iris,  colol)onia,  179 
Iritis,  71,  171 

Keratitis  parenchymatosa,  170,  175 

Labor,  100,  118,  212 
Lamina  basalis,  l(i7,  169 

cribrosa,  Ki,  21,  (Hi 

elastica,  l(i7,  109 

supracborioidea,   IfiT,  1G9 

vasciilosa,   1()7,   169 

vitrea,  167,  169 
Lead,  59    79 
Lens,  opacity  of,  73 
Leucocytba?niia,  102,  10+,  118,  119 

retinitis,  135,  150 
Level,    differences,    9,    102,    lOl,    105,    106,    130, 

152,  173,  181 
Light,  snbjective  sensations  of,  151 
Lymph  spaces  of  adventitia,  103 

Macula,  26,  112 

changes,  176,  20-1. 

arteriosclerotic,  127,  176,  204 
myo]iic,  see  Myopia 

colobonia,  177 

color,  '25 

coroniila,  55,  137 

hemorrhage,   118 

investigation,  7 

oedema,  1+9 

star,  130.  133,  138,  U3 

traumatic  i>crforation,  120 
Malaria,  neuritis,  73 

retinal  hemorrhages,  119 
Mediastinal  tumors,  73 

MeduUatcd  nerve  fibers,  35,  40,  48,  102,  128 
Meiosis,  54 
Meningitis,  73,  76,  77,  90 

serosa,  81 

syphilitic,  53,  76,  190,  19+ 

tiiberculous,  76,  218 
retinitis,  138 
Metamorphn]isia,  151,  181 
Methyl   alcohol.  59,  78 
Micro|)bthalmos,  179 
Miliary  tuberculosis,  125 

retinal  hemorrhages.   119 
Ilueller's  supporting  fibres.  130,  169 
Multiple  sclerosis,  52.  54,  59,  68,  79 
Mydriasis.  11.  52,  76 
Myelitis    (neuritis),  73 

Myopia,   .35,  etc.,   44,   etc.,   105.    118,   181,   182, 
206,  etc. 

changes  in  macula,  176,  206 

course  of  vessels,  25 

detachment,  151 

Naevus  of  retina,  138 

Nephritis,  see  Albuminuria 

Nerve   fibers,   varicose   thickening   of   the   lavcr 

of,  129 
Neuritic     atrojiby     of     the     optic     nerve,     seg 

Atro])hv 
Neuritis.  71,  86,"  100.  120 

albuminurica,  75.  76.  88,  134 

arteriosclerotica,  77,  88 

axialis.  78.  135 

bilateral,  72,  75 


Neuritis,   course   of,   74 

diabetica.  70,    142 

diffrrcMtial  diagnosis,  73 

etioi(»gy.  75 

in  otitis,  see  Otitis 

interstitial,  70 

ojjtic,  otogenous,  72,  77,  88 

otogenous,   77,  88 

retrobulbar,  58,  78 

sympathetic,  78,  148 

sy])liililic,  75,  86 

tuberculous,  70,   86,  218 
Neuroneuritis,  see    Neuritis  and    Retinitis 
Nicotin,  52,  59,  81 
Nystagmus,  59,  179 

Ocular  muscles,  paresis,  15+ 
CEdema  of  retina,  see  Retina 
O])hthalmoplegia,  54 
Optic  nerve,  anatomy,  15 
atro])hy.  ,iei    Atrophy 
colobonia,  33,  178 
hemorrhages,  83 
infiammation,  see  Neuritis 
injuries,  83 
interrujition,  103 
tubercle,  76,  83 
tunuirs,  83 
Optico-ciliarv  vessels.  2.3.  57,  105 
Orbit,  absces's,  81 
neuritis,  72,  77 
tumor,  81,  100,  101 
venous  engorgement,  102 
Otitis,  neuritis,  72,  77,  90 

dilatation   of   retinal   vessels,   100 
Otogenous  neuritis,  see  Neuritis 
Oxycephalus.  54,  72 
choked  disk,  81 
neuritis,  72 

Pachymeningitis,  82 

Papilla,  development  of  connective  tissue,  83 

hemorrhages,  83 

hy|)era'mia,  71 

indistinct,  73 

large.  17,  33 

normal,  16,  17,  28 

small.   17 
Papillo-macularv  bundles,  16,  59,  78 

atrophy,  52,"  59 
Paralactic  displacement.  9 
Paralysis,  5+ 

Paresis  of  ocular  muscles,  54,  59.  76 
Pepper  and  salt  fundus.  175 
Perineuritis,  76 

Peri]ia]iillarv  atrophy  of  chorioid,  see  Chorioid 
Perspective   dis])lacenicnt,   9 
l'hoto|isias.  151 
Phthisis    bulbi.    see    Uctacbinent    of    chorioid, 

181 
Pigment  of  chorioid,  23 

changes,  172.  etc. 

degeneration  of  retina,  see  Chorio-retinitis 

entrance  of  retina,  58,  64,  8S.  131.  150.  210 

eiutliclium,  layer  of    24,   112,  167,  169 

rins:.  18 

sjiots.  109 
Pigmentation,  sort,  172 
Plethora,  100 
Pneumonia,    101 

neurit's.  72 
PolMxtlia-Tuia.  101 


Porcupine,  eye  of,  53 

I'rejiMiiiH'y,  212 

I'rogiiosi.s   ill   changes   of   retina   ami   ehorioid, 

153 
Pseudo-neuritis,  71 

differential  diagnosis,  73 
Ptosis,  51 
Pupilla,  dilation,  10 

innniil)ilily,  ,j:i,  51,  59,  76 
Purpura,    retinal   lieniorrliages,   119 

Quinine,  59 

Raliltit,  11,  234. 
HeHex  light  streak,   103 
Keflex  of  retinal  vessels,  105 
Uefraction,  determination  of,  10 
Uetina,  anatomy,   11 1 
atrophy,  see  Atroj)hy 
changes,  jjosition  of,   113 

Jirognosis,   153 
delacliment,  see  Detachment 
differential  diagnosis,  119 
diffuse  opacities,  IW 
fatty  degeneration,  130,  133,  138 
fibrinous  exudates,  130,   1  Ki 
hemorrhages,  115,  IKi,  122.  133,  138 
intiltration    with   white   hlood   corjniscles,   150 
injuries,  118,  121 
oedema,  72,  73,  75,  7S,  8fi,   101,   102,  10«,  129, 

U9,  150,  178,  214. 
otitis,  77,  150 

pigment  invasion,  see  Migrating  Pigment 
prognosis,  153 
reflexes,  26,   104,   105,   128 
ruptures,  119 
tumors,  152 
veins,  pheboselerosis,  101 

thrombosis,  81,  99,  101,   102,  103,   117,  122, 
153 
vessels,    22,    25,    55,    97,    113,    117,    122,    126, 
152,  190,  202 
acconipan\ing   stripes,   57,   B4,   75,   99,    102, 

150,  156 
aneurism,  102,  144 
color,   102 
contraction,  98 

dilatation,  57,   73,  79,  92,  100,   117 
dnuinution,  104 
embolism,  see  Central  Artery 
fluctuations  in  caliber,  99 
glaucoma,  see  Glaucoma 
increase,  104 
lime  deposits,  103 
lym]>h  sjiaces,  103 
new   formations,  57,  101 
obliteration,  57,   104,  129,   153,  190 
phlebectasia,  102 

jihvsiological  differences,  99,  104,  208 
pulsation,  23,  99 
reflexes,  20,  103,  105 
sclerosis,  55,  99,  102,  106,  153,  190,  202 
thrombosis,  see   Retinal   Veins 
tortuositv,  100,  105 
Retinitis,  alb'uminnrica,  34,  99,  131,  133,  138,  etc. 
prognosis,  134,  154 
ana?mica,  135 
circinata,  134 
definition  of,  114 
diabetica,  99,   135,   144. 
prognosis,  153 


Retinitis,    diffusa,    149 

Icncirniica,  135,  150 

jjiguuiitosa,  see  Chorioretinitis 

I)rolilera,   103,   129,   135,   136,  144 

sei)tica,  125,  132 

syphilitica,   135,   146,  156 
Retraction  crescent,  36 
Rctriibnibar  neuritis,  58 
Rhinoceros,  eye  of,  53 

Sdelis'    lamj),    153 
Scarlet  fever,  lU'Uritis,  72 
(S'(7iirf(«n's  sheath,   16 
Scleractasia,  26,  181,  208,  223 
Scleral   ring,   18 

\'essels,  222 
Sclerosis  of  retinal  vessels,  see  Retinal  Vessels 

multiple,  see  Multiple  Sclerosis 
Sclerotic  vascular  ]ilexus,   15 
Sclerotico-chorioideal  canal,   19,  35 
Scotoma,   central,   54,  59,  68,   77,   181 
Scurvy,  119 

Secondary  glaucoma,  101 
Sepsis,  retinal   hemorrhages,  119 

white  spots,  125 
Sinus  cavcrnoMis,  15,  82 

thrombosis,  neuritis,  77,  90 
Small))<)x,  neuritis,  72 
Snuff   fundus,   175,  198 
.S)ihcnoidal  sinus,  59,  79 
Spots,  l)laek,   114,  169,  174 

white.  115,  125,  138,  169 
Sta]ihvlonia,  55 

posticum,  33,  37,  38,  46,  206 
changes  in  chorioidal  vessels,  35 

veriini.  26,  174,  181.  208 
Stijipled   fundus,  24,  28 
Strabismus,   179 
.Stri])es,  accompanying,   102 
Supertracti(ui  crescent,  19,  35,  44 
Svmpathetic     inflammation,     chorioidal     spots, 
127,  148 
neuritis,  78 
Synchysis   scintillans,   130 
Synco|ie,  99 

Syphilis,  see  Chorioretinitis,  53,  64,  73,  86,  117. 
129,  150,   171,   180,  210,  212 

atrophy,  53,  57,  76 

changes  in  retinal  vessels,  100,  122,  130,  153 

choked  disk.  81 

congenital,  73,  76,   174,  186,  190-202 

detachment.  152 

gunuiia,  see  Ciunima 

neuritis.  72.  75,  86 

retinal   hemorrhages,  118,  119 

retinitis.  135,  146,  149,  150,  156 
proliferans,  129,  144 

Tabes.  54,  see  Atrophy 

Technique,  3 

Temporal    detachment,   see    Atrophy   of   Optic 

Nerve 
Thrombosis    of  central   vein     78,   99,    101.    103, 

117,  122 
Tortuosity  of  vessels.  25 
Transverse   gunshot   wounds,   173.   182 
Trunk,  thrombosis  of.  117 
Tiilicrcle   of   ehorioid,   76,    130,    149,    179,   214 

of  brain.  81 

of  optic  nerve.  76.  82,  86 


229 


Tumor,  brain,  see  Brain 

chorioid,   15:?,  181 

detachment,  151 

intraocular,  luO,  105 

retina,  153 
Typhoid,  hemorrhages  of  retina,  119 

neuritis,  ~-2 

retinitis,  133 

Ulcus  ventriculi,  100 
Uraemia,  134 

Varicose    thickening    of    the    laver    of    nerve 

fibers,  l-'9 
Vena    centralis,   thrombosis,   see    Thrombosis 
ophthalmica,  15 


Venous  pulse,  23,  106 
Visual  field,  concentric,  54 
loss  of  sectors,  52,  54 
purple,  34 
Vitreous,  hemorrhage  into,  118 
opacities,  73 
prognosis,  154 
recurrent,  119 

Weiss-Otto  shadow  ring,  26 

Weiss'  reflex  ring,  36 

Werlhoff's  disease,  retinal  hemorrhages,  119 

Wounds,  transverse  gunshot,  173,  1»3 

Zinn's  sclerotic  vascular  plexus,  15,  23,  44,  68, 
168 


Ill 

il  li;  1,; 

^ 

D     000  141  974     6 

